Evaluating the Effectiveness of a Nutrition and Agricultural Linkages Project in Western Kenya: Design of the Mama SASHA Cohort Study of Vitamin A (COVA).

Objectives: The 2013 Lancet Maternal and Child Nutrition series identified rigorous evaluations of nutrition-sensitive agricultural interventions as a research priority. The Mama SASHA study in Western Kenya links delivery of vitamin A (VA) rich orange-flesh sweet potato (OFSP) vines to antenatal care to improve VA and nutritional status of pregnant and lactating women and their children. Methods: In addition to cross-sectional surveys in intervention and control communities at baseline and endline, the evaluation strategy includes a nested longitudinal study that follows women and their infants from pregnancy through 9 months postpartum. VA status of mothers and their infants is assessed during four visits using infection-adjusted plasma retinol binding protein and breast milk retinol (postpartum). Maternal and child iron and anemia status, anthropometry, dietary intakes, agricultural practices, health services uptake, household food security and program uptake are also measured Results: 505 eligible pregnant women, attending ANC at 4 control and 4 intervention facilities, were consented and enrolled. At enrollment overall prevalence of infection adjusted vitamin A deficiency was 21.8%. Women in control and intervention communities did not differ with respect to VA, iron, anemia or anthropometric status; household food security or dietary diversity scores; demographic characteristics; awareness of vitamin A; or consumption of vitamin A rich foods in the past 7 days. Only 10 women had consumed OFSP in the previous 7 days; all in intervention communities. Conclusions: The longitudinal study will contribute to rigorous impact evaluation of the OFSP intervention on maternal and child VA status and allow assessment of program impact pathways.

Determinants of Vitamin A Status among Pregnant Women Participating in the Mama SASHA Cohort Study of Vitamin A in Western Kenya: Preliminary Findings.

Objectives: Mothers' vitamin A (VA) status during pregnancy and lactation determine infants' VA levels. We estimated VA status during pregnancy and assessed its determinants using data on 505 pregnant women attending first antenatal care visit in Western Kenya. Methods: VA and iron status were assessed using plasma retinol binding protein (RBP), and ferritin and transferrin receptor, respectively, corrected for inflammation as measured by C-reactive protein (CRP>5 mg/L) and alpha-1-acid glycoprotein (>1 g/L)]. Anemia was assessed with Hemocue hemoglobinometer. Results: Only 34% of women had heard of VA, and 26% of them could not specify its importance. School was the most common source of VA information (68%), followed by health facility (19%). Mean (±SD) RBP was 1.44 (±0.35) μmol/l and the prevalence of VA deficiency (VAD) was 21.8%. Prevalence of inflammation (by CRP) was 24%. Anemia, but not iron deficiency, was the only factor associated with VAD (OR (CI): 1.68 (1.05, 2.71). Other potentially modifiable factors, including food insecurity, dietary diversity, awareness of VA, household or maternal consumption of VA rich foods, maternal MUAC and gestational age were not associated with VAD. Conclusions: The prevalence of VAD is high among pregnant women in Western Kenya and associated with anemia but not iron deficiency. Additional research is needed to understand the etiology of VAD in this population.

A Formative Research Study to Integrate Home Fortification of Complementary Foods into a Family Health Program in Bihar: Process and Methodology.

Objectives: The objective of this formative research was to develop a locally appropriate home fortification program for children (6-24mo) and to explore feasibility and acceptability within an integrated family health program in Bihar. Methods: The study consisted of three phases over a six month period. In Phase 1, we tested the acceptability of multiple micronutrient powders and developed contextualized packaging and counseling materials integrated with existing complementary feeding messages. We used focus group discussions (FGD, n=11) with frontline workers (FLWs), community members, mothers, mothers-in-law, and fathers to obtain feedback on product and supportive tools. In Phase 2, we explored community acceptability in 27 households (HHs) with children 6-24mo using a Trials of Improved Practices methodology. In-depth interviews (IDI) were held with HHs at baseline, midline and endline (day 10). Phase 3 was designed to evaluate the implementation process using existing program delivery platforms with FLWS in 3 health sub-centers (HSC). FLWs were trained to distribute products and counsel HHs on home fortification and complementary feeding. 5 FGDs and 3 IDIs were held with FLWs in addition to monthly HH monitoring data (n=20/HSC). Results: As a result of this formative work, counseling materials, FLW trainings and delivery approach were substantially revised to better reflect local context and program realities. Preliminary data suggest home fortification is well-accepted by community members and FLWs are willing to incorporate into existing work activities. Conclusions: This formative research methodology was vital for developing an integrated and locally acceptable home fortification program and informing future scale-up activities.