Caregiver behaviors and attitudes in the home use of lipid-based nutrient supplements for treating underweight children in Malawi

Undernutrition is an important public health problem that affects millions of children. It contributes to poor health and mortality and has negative consequences that continue into adulthood. The burden of child undernutrition is highest in sub-Saharan Africa. Strategies for improving nutritional status have usually targeted dietary intake. Providing supplementary or better complementary food is one of the most direct interventions for the problem of child undernutrition. To implement effective supplementary feeding interventions, it is essential to understand the sociocultural and behavioral factors that affect how supplementary foods are used in a particular setting. Such information can be used to design improved supplementary feeding programs. The present study took place in Malawi, a long, narrow landlocked country in southeast Africa with high levels of some forms of child undernutrition. This research was carried out in the same rural area of Mangochi District where clinical trials testing the effectiveness of a new type of supplementary food, lipid-based nutrient supplements (LNS), for treating underweight 6-17-month-olds and for preventing undernutrition were underway. Other members of the research team focused on the growth and development outcomes of children receiving LNS as compared to a common supplement, corn-soy blend (CSB), whereas this research investigated sociocultural aspects of supplementary food use. The study was situated within the positivist scientific tradition and it assessed the feasibility of compliance with supplementary feeding interventions in this setting. Its main aim was to identify caregivers attitudes, practices, and behaviors related to the home use of LNS. We investigated feeding patterns and caregiver behaviors before and during LNS use (n=16), how patterns of LNS use changed over time (n=16), how the supplement was used during illness and convalescence (n=16), and how its use compared to that of CSB (LNS n=85, CSB n=85). Quantitative and qualitative data on mothers attitudes towards LNS and CSB were also obtained (LNS n=249, CSB n=255). Data were collected through direct observations and interviews. The majority of the data were obtained in 2005 and 2006, but interviews on maternal attitudes continued until mid-2008. As compared to feeding practices at baseline and during CSB supplementation, use of LNS did not affect the frequency of feeding solid foods, the number or duration of breastfeeds, or the total amount of time spent feeding the child. When LNS was provided in jars containing a 5-day supply, caregivers first tried giving it in different ways, but after four weeks of use they integrated LNS into their regular feeding regimen by nearly always adding it to porridge. When LNS was provided in packets for daily use, it was more often eaten plain than mixed with porridge. As compared to CSB, LNS was less frequently offered as a meal, caregivers washed their hands less often before feeding it, and it was less likely that some of the supplement was left over at the end of a feeding episode. The same types of behavioral patterns were identified when plain LNS was compared to LNS mixed with porridge, indicating that most of the differences in behaviors during CSB and LNS supplementation were linked to the distinctive behaviors associated with plain LNS. The presence of leftovers at the end of supplementary feeding episodes was associated with low child weight-for-age. LNS consumption was significantly lower on days when the child was ill. The reduction in mean consumption was about 15%. LNS intake was lowest on days with fever, followed by days when the child had diarrhea. There was no difference in LNS intake on convalescent and healthy days. Maternal attitudes towards LNS and CSB were generally similar. Mothers reported that both supplements were highly acceptable, most children adapted to eating them within two weeks, and mothers would be willing to use them again or buy them. Supplements tended to be thought of as food rather than medicine. Mothers whose children were in the LNS group were willing to pay more than those in the CSB group for a one-week supply of the supplement. They were also more likely to say that they would withhold the supplement during cough because the sweetness could worsen symptoms. Maternal education was negatively associated and child s initial weight-for-height z-score was positively associated with maternal attitudes towards withholding of supplements during fever, diarrhea, and cough. Similar attitudes towards LNS and CSB suggest that caregivers would have little trouble adopting LNS, if it were to replace CSB, in supplementary feeding programs. The sweetness of LNS may deter its use during cough, indicating that a less sweet version of LNS might be beneficial in this setting. As use of LNS during illness and convalescence is good, programs could promote its use during these periods as a possible way of maintaining nutritional status. LNS supplementary feeding programs might be able to influence the way the supplements are used by providing clear messages that promote specific caregiver behaviors, such as hand washing before supplement meals and mixing LNS in a small amount of porridge to minimize leftovers.Undernutrition is an important public health problem that affects millions of children. It contributes to poor health and mortality and has negative consequences that continue into adulthood. The burden of child undernutrition is highest in sub-Saharan Africa. Strategies for improving nutritional status have usually targeted dietary intake. Providing supplementary or better complementary food is one of the most direct interventions for the problem of child undernutrition. To implement effective supplementary feeding interventions, it is essential to understand the sociocultural and behavioral factors that affect how supplementary foods are used in a particular setting. Such information can be used to design improved supplementary feeding programs. The present study took place in Malawi, a long, narrow landlocked country in southeast Africa with high levels of some forms of child undernutrition. This research was carried out in the same rural area of Mangochi District where clinical trials testing the effectiveness of a new type of supplementary food, lipid-based nutrient supplements (LNS), for treating underweight 6-17-month-olds and for preventing undernutrition were underway. Other members of the research team focused on the growth and development outcomes of children receiving LNS as compared to a common supplement, corn-soy blend (CSB), whereas this research investigated sociocultural aspects of supplementary food use. The study was situated within the positivist scientific tradition and it assessed the feasibility of compliance with supplementary feeding interventions in this setting. Its main aim was to identify caregivers attitudes, practices, and behaviors related to the home use of LNS. We investigated feeding patterns and caregiver behaviors before and during LNS use (n=16), how patterns of LNS use changed over time (n=16), how the supplement was used during illness and convalescence (n=16), and how its use compared to that of CSB (LNS n=85, CSB n=85). Quantitative and qualitative data on mothers attitudes towards LNS and CSB were also obtained (LNS n=249, CSB n=255). Data were collected through direct observations and interviews. The majority of the data were obtained in 2005 and 2006, but interviews on maternal attitudes continued until mid-2008. As compared to feeding practices at baseline and during CSB supplementation, use of LNS did not affect the frequency of feeding solid foods, the number or duration of breastfeeds, or the total amount of time spent feeding the child. When LNS was provided in jars containing a 5-day supply, caregivers first tried giving it in different ways, but after four weeks of use they integrated LNS into their regular feeding regimen by nearly always adding it to porridge. When LNS was provided in packets for daily use, it was more often eaten plain than mixed with porridge. As compared to CSB, LNS was less frequently offered as a meal, caregivers washed their hands less often before feeding it, and it was less likely that some of the supplement was left over at the end of a feeding episode. The same types of behavioral patterns were identified when plain LNS was compared to LNS mixed with porridge, indicating that most of the differences in behaviors during CSB and LNS supplementation were linked to the distinctive behaviors associated with plain LNS. The presence of leftovers at the end of supplementary feeding episodes was associated with low child weight-for-age. LNS consumption was significantly lower on days when the child was ill. The reduction in mean consumption was about 15%. LNS intake was lowest on days with fever, followed by days when the child had diarrhea. There was no difference in LNS intake on convalescent and healthy days. Maternal attitudes towards LNS and CSB were generally similar. Mothers reported that both supplements were highly acceptable, most children adapted to eating them within two weeks, and mothers would be willing to use them again or buy them. Supplements tended to be thought of as food rather than medicine. Mothers whose children were in the LNS group were willing to pay more than those in the CSB group for a one-week supply of the supplement. They were also more likely to say that they would withhold the supplement during cough because the sweetness could worsen symptoms. Maternal education was negatively associated and child s initial weight-for-height z-score was positively associated with maternal attitudes towards withholding of supplements during fever, diarrhea, and cough. Similar attitudes towards LNS and CSB suggest that caregivers would have little trouble adopting LNS, if it were to replace CSB, in supplementary feeding programs. The sweetness of LNS may deter its use during cough, indicating that a less sweet version of LNS might be beneficial in this setting. As use of LNS during illness and convalescence is good, programs could promote its use during these periods as a possible way of maintaining nutritional status. LNS supplementary feeding programs might be able to influence the way the supplements are used by providing clear messages that promote specific caregiver behaviors, such as hand washing before supplement meals and mixing LNS in a small amount of porridge to minimize leftovers

Perceptions of Child Body Size and Health Care Seeking for Undernourished Children in Southern Malawi

Child undernutrition affects millions of children globally, but little is known about the ability of adults to detect different types of child undernutrition in low-income countries. We used focused ethnographic methods to understand how Malawian parents and grandparents describe the characteristics they use to identify good and poor child growth, their actual or preferred patterns of health seeking for undernourished children, and the perceived importance of child undernutrition symptoms in relation to other childhood illnesses. Malawians value adiposity rather than stature in assessing child growth. Symptoms of malnutrition, including wasting and edema, were considered the least severe childhood illness symptoms. Parents delayed health care seeking when a child was ill. When they sought care, it was for symptoms such as diarrhea or fever, and they did not recognize malnutrition as the underlying cause. These findings can be used to tailor strategies for preventing and treating growth faltering in Malawian children

Drivers of food consumption among overweight mother-child dyads in Malawi

To address the increase in overweight and obesity among mothers and children in sub-Saharan Africa, an understanding of the factors that drive their food consumption is needed. We hypothesized food consumption in Malawi is driven by a combination of factors, including season, food accessibility (area of residence, convenience of purchasing food, female autonomy), food affordability (household resources, food expenditures, household food insecurity), food desirability (taste preferences, body size preferences), demographics, and morbidity. Participants in Lilongwe and Kasungu Districts were enrolled across three types of mother-child dyads: either the mother (n = 120), child (n = 80), or both (n = 74) were overweight. Seven-day dietary intake was assessed using a quantitative food frequency questionnaire during the dry and rainy seasons. Drivers associated with intake of calories, macronutrients, and 11 food groups at p<0.1 in univariate models were entered into separate multivariate linear regression models for each dietary intake outcome. Mother-child dyads with an overweight child had a higher percent of calories from carbohydrates and lower percent of calories from fat compared to dyads with a normal weight child (both p<0.01). These mothers also had the highest intake of grains (p<0.01) and their children had the lowest intake of oil/fat (p = 0.01). Household food insecurity, maternal taste preferences, and maternal body size preferences were the most consistent predictors of food group consumption. Household food insecurity was associated with lower intake of grains, fruits, meat and eggs, oil/fat, and snacks. Maternal taste preferences predicted increased consumption of grains, legumes/nuts, vegetables, fish, and oil/fat. Maternal body size preferences for herself and her child were associated with consumption of grains, legumes/nuts, dairy, and sweets. Predictors of food consumption varied by season, across food groups, and for mothers and children. In conclusion, indicators of food affordability and desirability were the most common predictors of food consumption among overweight mother-child dyads in Malawi

Group cell phones are feasible and acceptable for promoting optimal breastfeeding practices in a women's microcredit program in Nigeria

As part of a breastfeeding promotion intervention trial in Nigeria, we provided one cell phone per group of 5-7 microcredit clients, and instructed the group's cell phone recipient to share weekly breastfeeding voice and text messages with group members. We measured the feasibility and acceptability of using group cell phones by conducting semi-structured exit interviews with 195 microcredit clients whose babies were born during the intervention (target group), in-depth interviews with 8 phone recipients and 9 non-phone recipients, and 16 focus group discussions (FGDs) with other microcredit clients. Women in the target group said the group phone worked well or very well (64%). They were motivated to try the recommended practices because they trusted the information (58%) and had support from others (35%). Approximately 44% of target women reported that their groups met and shared messages at least once a week. Women in groups that met at least weekly had higher odds of exclusive breastfeeding up to 6 months (OR 5.6, 95% CI 1.6, 19.7) than women in groups that never met. In-depth interviews and FGDs indicated that non-phone recipients had positive feelings toward phone recipients, the group phone met participants’ needs, and messages were often shared outside the group. In conclusion, group cell phone messaging to promote breastfeeding among microcredit clients is feasible and acceptable, and can be part of an effective behavior change package

Factors associated with early growth in Egyptian infants: implications for addressing the dual burden of malnutrition

Optimal nutrition is critical to the attainment of healthy growth, human capital and sustainable development. In Egypt, infants and young children face overlapping forms of malnutrition, including micronutrient deficiencies, stunting and overweight. Yet, in this setting, little is known about the factors associated with growth during the first year of life. A rise in stunting in Lower Egypt from 2005 to 2008 prompted this implementation research study, which followed a longitudinal cohort of infants from birth to 1 year of age within the context of a USAID-funded maternal and child health integrated programme. We sought to determine if growth patterns and factors related to early growth differed in Lower and Upper Egypt, and examined the relationship between weight loss and subsequent stunting at 12 months of age. Growth patterns revealed that length-for-age z-score (LAZ) decreased and weight-for-length z-score (WLZ) increased from 6 to 12 months of age in both regions. One-quarter of infants were stunted and nearly one-third were overweight by 12 months of age in lower Egypt. Minimum dietary diversity was significantly associated with WLZ in Lower Egypt (β = 0.22, P < 0.05), but not in Upper Egypt. Diarrhoea, fever and programme exposure were not associated with any growth outcome. Weight loss during any period was associated with a twofold likelihood of stunting at 12 months in Lower Egypt, but not Upper Egypt. In countries, like Egypt, facing the nutrition transition, infant and young child nutrition programmes need to address both stunting and overweight through improving dietary quality and reducing reliance on energy-dense foods

Factors associated with early growth in Egyptian infants: implications for addressing the dual burden of malnutrition.

Optimal nutrition is critical to the attainment of healthy growth, human capital and sustainable development. In Egypt, infants and young children face overlapping forms of malnutrition, including micronutrient deficiencies, stunting and overweight. Yet, in this setting, little is known about the factors associated with growth during the first year of life. A rise in stunting in Lower Egypt from 2005 to 2008 prompted this implementation research study, which followed a longitudinal cohort of infants from birth to 1 year of age within the context of a USAID-funded maternal and child health integrated programme. We sought to determine if growth patterns and factors related to early growth differed in Lower and Upper Egypt, and examined the relationship between weight loss and subsequent stunting at 12 months of age. Growth patterns revealed that length-for-age z-score (LAZ) decreased and weight-for-length z-score (WLZ) increased from 6 to 12 months of age in both regions. One-quarter of infants were stunted and nearly one-third were overweight by 12 months of age in lower Egypt. Minimum dietary diversity was significantly associated with WLZ in Lower Egypt (β = 0.22, P \u3c 0.05), but not in Upper Egypt. Diarrhoea, fever and programme exposure were not associated with any growth outcome. Weight loss during any period was associated with a twofold likelihood of stunting at 12 months in Lower Egypt, but not Upper Egypt. In countries, like Egypt, facing the nutrition transition, infant and young child nutrition programmes need to address both stunting and overweight through improving dietary quality and reducing reliance on energy-dense foods

Infant and Young Child Feeding Counseling, Decision-Making, and Practices Among HIV-Infected Women in Malawi’s Option B+ Prevention of Mother-to-Child Transmission Program: A Mixed Methods Study

This study examined infant and young child feeding (IYCF) counseling, decision-making, and practices among HIV-infected women with children 0–23 months participating in Malawi’s Option B+ prevention of mother-to-child transmission (PMTCT) program. We conducted 160 survey interviews, 32 in-depth interviews, and 32 observations of PMTCT visits. Surveys indicated that exclusive breastfeeding was common (75%) among children < 6 months, while minimum dietary diversity (41%) and minimum acceptable diet (40%) for children 6–23 months occurred less often. In-depth interviews supported these findings. Most women felt comfortable with current breastfeeding recommendations, but chronic food insecurity made it difficult for them to follow complementary feeding guidelines. Women trusted IYCF advice from health workers, but mainly received it during pregnancy. During observations of postnatal PMTCT visits, health workers infrequently advised on breastfeeding (41% of visits) or complementary feeding (29% of visits). This represents a missed opportunity for health workers to support optimal IYCF practices within Option B+

Integrating Group Counseling, Cell Phone Messaging, and Participant-Generated Songs and Dramas into a Microcredit Program Increases Nigerian Women's Adherence to International Breastfeeding Recommendations

In northern Nigeria, interventions are urgently needed to narrow the large gap between international breastfeeding recommendations and actual breastfeeding practices. Studies of integrated microcredit and community health interventions documented success in modifying health behaviors but typically had uncontrolled designs. We conducted a cluster-randomized controlled trial in Bauchi State, Nigeria, with the aim of increasing early breastfeeding initiation and exclusive breastfeeding among female microcredit clients. The intervention had 3 components. Trained credit officers led monthly breastfeeding learning sessions during regularly scheduled microcredit meetings for 10 mo. Text and voice messages were sent out weekly to a cell phone provided to small groups of microcredit clients (5–7 women). The small groups prepared songs or dramas about the messages and presented them at the monthly microcredit meetings. The control arm continued with the regular microcredit program. Randomization occurred at the level of the monthly meeting groups. Pregnant clients were recruited at baseline and interviewed again when their infants were aged ≥6 mo. Logistic regression models accounting for clustering were used to estimate the odds of performing recommended behaviors. Among the clients who completed the final survey (n = 390), the odds of exclusive breastfeeding to 6 mo (OR: 2.4; 95% CI: 1.4, 4.0) and timely breastfeeding initiation (OR: 2.6; 95% CI: 1.6, 4.1) were increased in the intervention vs. control arm. Delayed introduction of water explained most of the increase in exclusive breastfeeding among clients receiving the intervention. In conclusion, a breastfeeding promotion intervention integrated into microcredit increased the likelihood that women adopted recommended breastfeeding practices. This intervention could be scaled up in Nigeria, where local organizations provide microcredit to >500,000 clients. Furthermore, the intervention could be adopted more widely given that >150 million women, many of childbearing age, are involved in microfinance globally. This trial was registered at clinicaltrials.gov as NCT01352351