How do programs work to improve child nutrition?: Program impact pathways of three nongovernmental organization intervention projects in the Peruvian highlands

This paper examines the program logic of three nongovernmental, community-based programs with different intervention models to reduce childhood stunting. Two programs, Child Nutrition Program (PNI) and Good Start, focused directly on education and behavior change among caregivers, or the short routes to achieve impact, while one program, Sustainable Networks for Food Security (REDESA), focused on upstream factors, such as improving local governance and coordination, improving water and sanitation, and increasing family incomes, or the long routes to achieve impact. We compared the logic of each program as it was explicitly documented to the logic as perceived by the implementers. We elucidated the program impact pathways (PIPs) of key activities by actors at different operational levels in each program to identify congruencies and gaps in the perceptions of causal mechanisms between program activities and their intended outcomes, and analyzed them with the simple program models and logical frameworks to highlight the methodology and utility of PIPs. In a desire to move beyond static input-out models of the three programs, we designed and conducted data collection activities (document review, semi-structured interviews, and observations) with the intention of gaining insights about those aspects of the program that brought causal mechanisms of a given program into clearer focus. We propose that different methods for eliciting PIPs may be necessary at different operational levels. The interview method elicited more complete responses among those who are familiar with programmatic concepts, whereas actors at the local operational level provided sparse and fragmentary responses, even when simple, common language was used during the interviews. Group participatory processes, using visual aids, may be more effective for mapping the perceptions of those who are not accustomed to articulating information about programs. To reduce the length and frequency of interviews with program actors, initial PIPs could also be constructed from program documents, then discussed and revised iteratively with program actors. Although program logic models and the logical frameworks provide a succinct overview of the program (for communication, strategic planning, and management), we found that PIPs provide a better representation of the causal connections between program activities and results, particularly when both upstream and direct intervention activities were part of the same program. PIPs provide a visual tool for tracking how activities were perceived to work and make an impact, bringing into focus the different pathways of the activities and influences along the way. Beyond the logical sequence of program inputs, outputs, and outcomes, the conceptualization of impact pathways is a useful approach for understanding the causal connections required for impact and for identifying where attention and reinforcements may be required within program operation. The utility of this tool warrants its use not only during final evaluation but also during mid-program monitoring and relevant assessments. National- and regional-level program actors had good understanding of the overarching frameworks and principles of their respective programs as well as the program components and activities. They demonstrated a strong coherence to the program documents, provided similar cohesive responses, and were able to articulate the impact pathways. However, program actors at the national level identified fewer facilitators and barriers along the impact pathways than did the local actors, revealing that the practical dimensions of the impact pathways were not as evident to planners and managers farther from the communities. Although program actors at the local level were more apt to provide practical examples of influencing factors or incidents that occur during implementation, they had difficulty fully articulating their perceived PIPs and provided fragmented views of how the activities linked to their outcomes. Similar patterns were found across the three programs. This finding raises the question of desirability of a common understanding of the goals and pathways by which these outcomes are achieved or the acceptability of diversity of perspectives. It is still unclear whether program effectiveness may be improved through greater congruency in the PIPs. Future research should elucidate how congruency of PIPs among program actors across operational levels could be increased, and whether greater congruency would improve program implementation and effectiveness.program impact pathway, program logic model, logical framework, childhood stunting, child nutrition programs,

Approaches to Assessing Context and Culture in International Nutrition Education Programs

The purpose of this paper is to explore how context and culture affected the nutrient intakes and complementary feeding (process of feeding solid foods in addition to breast milk) practices of 6 to 12 month old infants in sub-Saharan Africa to generate appropriate nutrition education approaches

School-Based Deworming Program Yields Small Improvement in Growth of Zanzibari School Children After one Year.

Efficacy trials of antihelminthic therapies conducted in Africa have reported improvements in children's growth, but nutritional evaluations of large-scale deworming programs are lacking. We evaluated the first-year effect on growth of a school-based deworming program in Zanzibar, where growth retardation occurs in school children. Children in four primary schools were given thrice-yearly mebendazole (500 mg) and compared with children in four schools that received twice-yearly mebendazole and children in four non-program schools. Evaluation schools were randomly selected and allocated to control, twice-yearly or thrice-yearly deworming. Approximately 1000 children in each program group completed the 1-y follow-up. Children <10 y old gained 0.27 kg more weight (P < 0.05) and 0.13 cm more height (P = 0.20) in the twice-yearly group, and 0. 20 kg more weight (P = 0.07) and 0.30 cm more height (P < 0.01) in the thrice-yearly group, compared with the control group. Children <10 y old with higher heights-for-age at baseline had higher weight and height gains in response to deworming. In children >/=10 y old, overall program effects on height or weight gains were not significant. But in this age range, younger boys had significant improvements in height gain with thrice-yearly deworming, and children with higher heights-for-age had greater improvements in weight gain with deworming. We conclude that the deworming program improved the growth of school children, especially children who were younger and less stunted, but the improvements were small. More effective antihelminthic regimens or additional dietary or disease control interventions may be needed to substantially improve the growth of school children in areas such as Zanzibar

Low Dose Daily Iron Supplementation Improves Iron Status and Appetite but not Anemia, Whereas Quarterly Anthelminthic Treatment Improves Growth, Appetite and Anemia in Zanzibari Preschool Children.

Iron deficiency and helminth infections are two common conditions of children in developing countries. The consequences of helminth infection in young children are not well described, and the efficacy of low dose iron supplementation is not well documented in malaria-endemic settings. A 12-mo randomized, placebo controlled, double-blind trial of 10 mg daily iron and/or mebendazole (500 mg) every 3 mo was conducted in a community-based sample of 459 Zanzibari children age 6-71 mo with hemoglobin > 70 g/L at baseline. The trial was designed to examine treatment effects on growth, anemia and appetite in two age subgroups. Iron did not affect growth retardation, hemoglobin concentration or mild or moderate anemia (hemoglobin < 110 g/L or < 90 g/L, respectively), but iron significantly improved serum ferritin and erythrocyte protoporphyrin. Mebendazole significantly reduced wasting malnutrition. but only in children <30 mo old. The adjusted odds ratios (AORs) for mebendazole in this age group were 0.38 (95% CI: 0.16, 0.90) for weight-for-height less than -1 Z-score and 0.29 (0.09, 0.91) for small arm circumference. In children <24 mo old, mebendazole also reduced moderate anemia (AOR: 0.41, 0.18, 0.94). Both iron and mebendazole improved children's appetite, according to mothers' report. In this study, iron's effect on anemia was limited, likely constrained by infection, inflammation and perhaps other nutrient deficiencies. Mebendazole treatment caused unexpected and significant reductions in wasting malnutrition and anemia in very young children with light infections. We hypothesize that incident helminth infections may stimulate inflammatory immune responses in young children, with deleterious effects on protein metabolism and erythropoiesis

Bacterial Populations in Complementary Foods and Drinking-water in Households with Children Aged 10-15 Months in Zanzibar, Tanzania

Bacteria were quantified in samples of drinking-water and in two porridges prepared for infant-feeding [fortified instant soy-rice porridge (SRP) and cooked porridge (Lishe bora, LB)] in 54 households. Bacterial numbers were measured again after the porridges had been held at room temperature for four hours (T4). Findings were benchmarked against bacterial numbers in traditional complementary foods sampled from 120 households. Total bacteria, coliform, and Enterobacteriaceae counts were enumerated using Petrifilm™. The mean log bacterial numbers were the lowest for LB at T0 (2.24±0.84 cfu/g aerobic counts) and the highest for SRP at T4 (4.63±0.56 cfu/g aerobic counts). The total bacteria, coliform and Enterobacteriaceae counts were higher at T4 than at T0 for LB (p≤0.001); however, only the coliform and Enterobacteriaceae counts were higher at T4 than at T0 for SRP (p<0.001). Drinking-water, SRP0, traditional foods, and SRP4 all had the mean aerobic counts higher than the acceptable cut-off but the total bacterial count in SRP0 was not significantly (p=0.543) different from drinking-water. However, coliform and Enterobacteriaceae counts in SRP0 were higher than in drinking-water (p<0.001). Also, although the aerobic counts of SRP4 were not significantly (p>0.999) different from traditional foods, the coliform and Enterobacteriaceae counts were significantly higher in SRP4 than in traditional foods (p<0.001). It is, therefore, recommended that food safety concerns be addressed when improving complementary foods

Association between Anaemia during Pregnancy and Blood Loss at and after Delivery among Women with Vaginal Births in Pemba Island, Zanzibar, Tanzania

The study sought to identify determinants of blood loss at childbirth and 24 hours postpartum. The study was nested in a community-based randomized trial of treatments for anaemia during pregnancy in Wete Town, Pemba Island, Zanzibar, United Republic of Tanzania. Status of anaemia during pregnancy, nutritional information, obstetric history, and socioeconomic status were assessed at enrollment during routine antenatal care. Pregnant women presented for spontaneous vaginal delivery, and nurse-midwives collected information on labour and delivery via partograph. Blood-stained sanitary napkins and pads from childbirth and 24 hours postpartum were quantified using the alkaline hematin method. Moderate-to-severe anaemia (Hb <90 g/L) at enrollment was strongly associated with blood loss at delivery and the immediate postpartum period, after adjusting for maternal covariates and variables of biological relevance to blood loss. Greater blood loss was associated (p<0.10) with duration of the first stage of labour, placental weight, receipt of oxytocin, preterm birth, and grand multiparity. The findings provide unique evidence of a previously-suspected link between maternal anaemia and greater blood loss at childbirth and postpartum. Further research is needed to confirm these findings on a larger sample of women to determine whether women with moderate-to-severe anaemia are more likely to experience postpartum haemorrhage and whether appropriate antenatal or peripartum care can affect the relationships described here

Reply to Correspondence: is the strength of association between indicators of dietary quality and the nutritional status of children being underestimated?

Peer Reviewedhttp://deepblue.lib.umich.edu/bitstream/2027.42/102165/1/mcn12107.pd

Inconsistent Effects of Iron-Folic Acid and/or Zinc Supplementation on the Cognitive Development of Infants

Despite concerns over the neurocognitive effects of micronutrient deficiencies in infancy, few studies have examined the effects of micronutrient supplementation on specific cognitive indicators. This study investigated, in 2002, the effects of iron-folic acid and/or zinc supplementation on the results of Fagan Test of Infant Intelligence (FTII) and the A-not-B Task of executive functioning among 367 Nepali infants living in Sarlahi district. Infants were enrolled in a cluster-randomized, placebo-controlled clinical trial of daily supplementation with 5 mg of zinc, 6.25 mg of iron with 25 µg of folic acid, or zinc-iron-folic acid, or placebo. These were tested on both the tasks using five indicators of information processing: preference for novelty (FTII), fixation duration (FTII), accelerated performance (≥85% correct; A-not-B), deteriorated performance (<75% correct and >1 error on repeat-following-correct trails; A-not-B), and the A-not-B error (A-not-B). At 39 and 52 weeks, 247 and 333 infants respectively attempted the cognitive tests; 213 made an attempt to solve both the tests. The likelihood of females completing the A-not-B Task was lower compared to males when cluster randomization was controlled [odds ratio=0.67; 95% confidence interval 0.46-0.97; p<0.05]. All of the five cognitive outcomes were modelled in linear and logistic regression. The results were not consistent across either the testing sessions or the information-processing indicators. Neither the combined nor the individual micronutrient supplements improved the performance on the FTII or the A-not-B Task (p>0.05). These findings suggest that broader interventions (both in terms of scope and duration) are needed for infants who face many biological and social stressors

The Role of Zinc and Iron-Folic Acid Supplementation on Early Child Temperament and Eating Behaviors in Rural Nepal: A Randomized Controlled Trial

Child eating behaviors play an important role in nutrient intake, ultimately affecting child growth and later outcomes in adulthood. The study assessed the effects of iron-folic acid and zinc supplementation on child temperament and child eating behaviors in rural Nepal. Children (N = 569) aged 4–17 months in Sarlahi district, southern Nepal were randomized to receive daily supplements of placebo, iron-folic acid, zinc, or zinc plus iron-folic acid and followed for approximately 1 year. At baseline and four follow-up visits mothers completed questionnaires including information on demographic characteristics and child temperament and eating behaviors. The main effects of zinc and iron-folic acid supplementation on temperament and eating behaviors were assessed through crude and adjusted differences in mean cumulative score changes between visits 1 and 5. The adjusted rate-of-change for these outcomes was modeled using generalized estimating equations. Mean changes in temperament scores and in eating behavior scores between visits 1 and 5 were not significant in either the zinc or non-zinc group. Children in the iron-folic acid group increased temperament scores by 0.37 points over 5 visits (95% CI 0.02, 0.7), which was not significant after adjustment. Neither the adjusted rate-of-change in temperament scores between zinc and non-zinc (β = −0.03, 95% CI −0.3, 0.2) or iron-folic acid and non-iron-folic acid (β = 0.08, 95% CI −0.2, 0.3) were significantly different. Adjusted rate of change analysis showed no significant difference between zinc and non-zinc (β = −0.14, 95% CI −0.3, 0.04) or between iron and non-iron eating behavior scores (β = −0.11, 95% CI −0.3, 0.1). Only among children with iron-deficiency anemia at baseline was there a significant decrease in eating behavior score, indicating better eating behaviors, when supplemented with zinc (β = −0.3, 95% CI −0.6, −0.01), Ultimately, this effect of zinc on eating behaviors was the only effect we observed after approximately one year of micronutrient supplementation

Cluster-randomized non-inferiority trial to compare supplement consumption and adherence to different dosing regimens for antenatal calcium and iron-folic acid supplementation to prevent preeclampsia and anaemia: rationale and design of the Micronutrient Initiative study

Background: To prevent pre-eclampsia in populations with insufficient dietary calcium (Ca) intake, the World Health Organisation (WHO) recommends routine Ca supplementation during antenatal care (ANC). WHO guidelines suggest a complex dosing regimen, requiring as many as 5 pill-taking events per day when combined with iron and folic acid (IFA) supplements. Poor adherence may undermine public health effectiveness, so simpler regimens may be preferable. This trial will compare the effect of the WHO-recommended (higher-dose) regimen vs. a simpler, lower-dose regimen on supplement consumption and pill-taking behaviours in Kenyan ANC clients. Design and methods: This is a parallel, non-inferiority, cluster-randomized trial; we examined 16 primary care health facilities in Kenya, 1047 pregnant women between 16-30 weeks gestational age. Higher-dose regimen: 1.5 g elemental calcium in 3 separate doses (500 mg Ca/pill) and IFA (60 mg Fe + 400 μg folic acid) taken with evening dose. Lower-dose regimen: 1.0 g calcium in 2 separate doses (500 mg Ca/pill) with IFA taken as above. Measurements: Primary outcome is Ca pills consumed per day, measured by pill counts. Secondary outcomes include IFA pills consumed per day, client knowledge, motivation, social support, and satisfaction, measured at 4 to 10 weeks post-enrolment. Statistical analyses: Unit of randomization is the health-care facility; unit of analysis is individual client. Intent-to-treat analysis will be implemented with multi-level models to account for clustering. Expected public health impact: If pregnant women prescribed lower doses of Ca ingest as many pills as women prescribed the WHO-recommended regimen, developing a lower-dose recommendation for antenatal Ca and IFA supplementation programs could save resources