Impact of Suaahara, an integrated nutrition programme, on maternal and child nutrition at scale in Nepal.

Suaahara was an innovative, complex, multi-sectoral, large-scale, nutrition programme in Nepal to increase exposure to nutrition-related information and services, improve nutrition-related knowledge and practices among pregnant women and mothers of infants and young children, and improve their nutrition. This study evaluated the effectiveness of Suaahara to improve nutrition and nutrition-related practices by comparing changes over 10 years between intervention and comparison districts. The samples of households at baseline in 2012 and endline in 2022 were 2040 and 2480, respectively, from 120 old wards. The impact was estimated using intent-to-treat regression models in which survey year, arm and their interaction were fixed effects, accounting for district clustering, with the interaction estimating differences between arms in changes over time. The intervention, relative to comparison, reduced maternal underweight by 8.43 percentage points (p < 0.001), consistent with improved maternal and fetal condition that was manifested as the greater length of 0.761 z-scores (p = 0.004) of infants 0-5.9 months. Complementary feeding practices with children between 6 and 23.9 months of age improved more in the intervention than comparison districts: child dietary diversity by 0.294 food groups (p = 0.072) and minimum dietary diversity by 9.51 percentage points (p = 0.028), feeding sick child more (p = 0.002) and administering oral rehydration solution and zinc for diarrhoea (p = 0.057) by about 17 percentage points each, and minimum meal frequency (p = 0.004) and minimum acceptable diet (p = 0.022) by about 15 percentage points each. Substantial impacts were demonstrated despite political restructuring, earthquakes, and other major challenges that Nepal and Suaahara faced and limitations in statistical power because of the reduced number of districts that then could be included in the study. Registered at clinicaltrials.gov with identifier NCT05448287.

Rates of Dual Diagnosis in Child and Adolescent Psychiatric Inpatients: A Scoping Review.

OBJECTIVES: Child and adolescent psychiatric (CAP) inpatient admissions have increased since 2009 and the clinical profile of these patients has become more complex. Unrecognized dual diagnosis, that is, comorbid substance use or substance use disorder (SUD) may contribute to this problem, but the prevalence of dual diagnosis in this population is inadequately understood. The goal of this scoping review was to summarize the range and content of research on this topic. METHODS: MEDLINE, EMBASE, and PsychINFO databases were systematically searched for studies published from 2008 to 2019 containing information on rates of comorbid substance use or SUD in CAP inpatients. RESULTS: A total of 23,326 abstracts were located. After removing duplicates, screening abstracts and full-text papers, and extracting data with full-text reviews, fourteen studies meeting our criteria remained. Rates of substance use or SUD ranged from 0.9% to 54.8%, differing on the basis of: (1) type of outcome; (2) type of data source; and (3) whether samples had a specific diagnostic focus or not. Rates of any type of SUD were reported in approximately 25% of samples from administrative databases, in 17.7% to 38.5% of chart reviews, and in 55% of studies with data from clinical research examinations. The highest rates of substance-specific substance use or SUD were for alcohol, cannabis, and nicotine. CONCLUSIONS: We located 14 studies, but methodologic heterogeneity precluded quantitative calculation of a single estimate for the prevalence of dual diagnosis. However, most of the rates suggest that this is an important problem in CAP inpatients, meriting further research. We suggest ways to improve future studies.

Degree of exposure to interventions influences maternal and child dietary practices: Evidence from a large-scale multisectoral nutrition program.

The prevalence of maternal and child malnutrition in Nepal is among the highest in the world, despite substantial reductions in the last few decades. One effort to combat this problem is Suaahara II (SII), a multi-sectoral program implemented in 42 of Nepal's 77 districts to improve dietary diversity (DD) and reduce maternal and child undernutrition. Using cross-sectional data from SII's 2017 annual monitoring survey, this study explores associations between exposure to SII and maternal and child DD. The study sample included 3635 mothers with at least one child under the age of five. We focused on three primary SII intervention platforms: interpersonal communication (IPC) by frontline workers, community mobilization (CM) via events, and mass media through a weekly radio program (Bhanchhin Aama); and also created an exposure scale to assess the dose-response relationship. DD was measured both as a continuous score and as a binary measure of meeting the recommended minimum dietary diversity of consuming foods from at least 5 of 10 food groups for mothers and at least 4 of 7 food groups for children. We used linear and logistic regression models, controlling for potentially confounding factors at the individual and household level. We found a positive association between any exposure to SII platforms and maternal DD scores (b = 0.09; p = 0.05), child (aged 2-5 years) DD scores (b = 0.11; p = 0.03), and mothers meeting minimum dietary diversity (OR = 1.16; p = 0.05). There were significant, positive associations between both IPC and CM events and meeting minimum DD (IPC: OR = 1.31, p = 0.05; CM: OR = 1.37; p<0.001) and also between CM events and DD scores (b = 0.14; p = 0.03) among mothers. We found significant, positive associations between mass media and meeting minimum DD (OR: 1.38; p = 0.04) among children aged 6-24 months and between mass media and DD scores (b = 0.15; p = 0.01) among children aged 2-5 years. We also found that exposure to all three platforms, versus fewer platforms, had the strongest association with maternal DD scores (b = 0.45; p = 0.01), child (aged 2-5 years) DD scores (b = 0.41; p<0.001) and mothers meeting MDD (OR = 2.33; p<0.001). These findings suggest that a multi-pronged intervention package is necessary to address poor maternal and child dietary practices and that the barriers to behavior change for maternal diets may differ from those for child diets. They also highlight the importance of IPC and CM for behavior change and as a pre-requisite to mass media programs being effective, particularly for maternal diets.

From didactic to personalized health and nutrition counselling: A mixed-methods review of the GALIDRAA approach in Nepal.

GALIDRAA (greet, ask, listen, identify, discuss, recommend, agree, and appoint), an interpersonal communication method, is used in health and nutrition behaviour change programmes to structure communication between front-line workers (FLWs) and beneficiaries. However, programmatic experiential evidence and monitoring and evaluation of the method are scarce. Suaahara aims to address maternal and child undernutrition, in part by influencing household-level behaviours. Suaahara trained both government and programme FLWs in GALIDRAA for use during counselling. This study investigates their adherence to the GALIDRAA method 2 years later, using quantitative and qualitative data from a 2014 process evaluation study. Descriptive and thematic analyses were conducted to assess adherence to GALIDRAA. We found variation in adherence to each of the eight GALIDRAA steps among both Suaahara field supervisors (FSs) and Nepal's female community health volunteers (FCHVs). The prevalence of FLWs identifying a beneficiary's problem, discussing, questioning, and probing for constraints with the beneficiary, and, only then, recommending a doable solution, that is, the process of personalized nutrition counselling, was substantially higher among Suaahara FSs than FCHVs. However, both FCHVs and FSs counselling skills, particularly regarding adherence to each step of the GALIDRAA approach, have room for improvement. This highlights the need for additional training and post-training follow-up including supportive supervision related to appropriate counselling methods such as GALIDRAA and may indicate that there are additional FLWs constraints, beyond knowledge, that programmes need to address.

Deworming in non-pregnant adolescent girls and adult women: a systematic review and meta-analysis.

BACKGROUND: The impact of deworming on parasite load, nutritional status and other health outcomes of non-pregnant adolescent girls and adult women is uncertain. METHODS: MEDLINE, EMBASE, CINAHL, the Cochrane Central Register of Controlled Trials, the WHO International Clinical Trials Registry Platform, the Cochrane Database of Systematic Reviews and Food and Technology Abstracts databases were searched until 24 September 2018. Studies were included if they were randomised controlled trials (RCTs), controlled before and after studies or interrupted time studies comparing deworming with no intervention or placebo in non-pregnant adolescent girls and women 10 to 49 years old. Outcomes of interest included parasite load, reinfection, anaemia, severe anaemia, iron deficiency, diarrhoea or all-cause morbidity. Risk of bias was assessed using the Cochrane risk of bias tool. RESULTS: We included four RCTs of mass deworming involving 1086 participants, in the analyses. Mass deworming probably reduces the prevalence of roundworm infection (RR 0.29; 95% CI 0.14 to 0.62; 2 trials; 1498 participants, moderate certainty evidence), prevalence of hookworm infection (RR 0.32; 95% CI 0.18 to 0.59; 2 trials; 1498 participants, moderate certainty evidence), prevalence of whipworm infection (RR 0.77; 95% CI 0.65 to 0.91; 2 trials; 1498 participants, moderate certainty evidence) compared to the control group. Deworming may make little or no difference in prevalence of anaemia (RR 0.82; 95% CI 0.60 to 1.11, 3 studies, 683 participants, low certainty evidence) and prevalence of iron-deficiency (RR 0.89; 95% CI 0.64 to 1.23, 1 study, 186 participants, low certainty evidence) compared to control. We are uncertain whether deworming reduces the prevalence of severe anaemia compared to control as the certainty of evidence was very low. None of the included studies assessed screen and treat deworming or reported reinfection, diarrhoea or adverse events. CONCLUSIONS: Mass deworming probably reduces the prevalence of soil-transmitted helminth infections but may have little or no effect on anaemia and iron-deficiency in adolescent girls and non-pregnant women in comparison to no intervention or placebo. We are uncertain about the effect on severe anaemia. These results are limited by sparse data and the moderate to very low quality of evidence available. SYSTEMATIC REVIEW REGISTRATION: The protocol was registered in PROSPERO (registration number: CRD42016039557 ).  Primary source of funding: Evidence and Programme Guidance unit, Department of Nutrition for Health and Development, World Health Organization (WHO).

Mass deworming to improve developmental health and wellbeing of children in low-income and middle-income countries: a systematic review and network meta-analysis.

BACKGROUND: Soil-transmitted helminthiasis and schistosomiasis, considered among the neglected tropical diseases by WHO, affect more than a third of the world's population, with varying intensity of infection. We aimed to evaluate the effects of mass deworming for soil-transmitted helminths (with or without deworming for schistosomiasis or co-interventions) on growth, educational achievement, cognition, school attendance, quality of life, and adverse effects in children in endemic helminth areas. METHODS: We searched 11 databases up to Jan 14, 2016, websites and trial registers, contacted authors, and reviewed reference lists. We included studies published in any language of children aged 6 months to 16 years, with mass deworming for soil-transmitted helminths or schistosomiasis (alone or in combination with other interventions) for 4 months or longer, that reported the primary outcomes of interest. We included randomised and quasi-randomised trials, controlled before-after studies, interrupted time series, and quasi-experimental studies. We screened in duplicate, then extracted data and appraised risk of bias in duplicate with a pre-tested form. We conducted random-effects meta-analysis and Bayesian network meta-analysis. FINDINGS: We included 52 studies of duration 5 years or less with 1 108 541 children, and four long-term studies 8-10 years after mass deworming programmes with more than 160 000 children. Overall risk of bias was moderate. Mass deworming for soil-transmitted helminths compared with controls led to little to no improvement in weight over a period of about 12 months (0·99 kg, 95% credible interval [CrI] -0·09 to 0·28; moderate certainty evidence) or height (0·07 cm, 95% CrI -0·10 to 0·24; moderate certainty evidence), little to no difference in proportion stunted (eight fewer per 1000 children, 95% CrI -48 to 32; high certainty evidence), cognition measured by short-term attention (-0·23 points on a 100 point scale, 95% CI -0·56 to 0·14; high certainty evidence), school attendance (1% higher, 95% CI -1 to 3; high certainty evidence), or mortality (one fewer per 1000 children, 95% CI -3 to 1; high certainty evidence). We found no data on quality of life and little evidence of adverse effects. Mass deworming for schistosomiasis might slightly increase weight (0·41 kg, 95% CrI -0·20 to 0·91) and has little to no effect on height (low certainty evidence) and cognition (moderate certainty evidence). Our analyses do not suggest indirect benefits for untreated children from being exposed to treated children in the community. We are uncertain about effects on long-term economic productivity (hours worked), cognition, literacy, and school enrolment owing to very low certainty evidence. Results were consistent across sensitivity and subgroup analyses by age, worm prevalence, baseline nutritional status, infection status, impact on worms, infection intensity, types of worms (ascaris, hookworm, or trichuris), risk of bias, cluster versus individual trials, compliance, and attrition. INTERPRETATION: Mass deworming for soil-transmitted helminths with or without deworming for schistosomiasis had little effect. For schistosomiasis, mass deworming might be effective for weight but is probably ineffective for height, cognition, and attendance. Future research should assess which subset of children do benefit from mass deworming, if any, using individual participant data meta-analysis. FUNDING: Canadian Institutes of Health Research and WHO.

Crystal structure of (E)-N-[(2-meth-oxy-naphthalen-1-yl)methyl-idene]-3-nitro-aniline.

In the title compound, C18H14N2O3, the dihedral angle between the naphthalene ring system and the benzene ring is 59.99 (13)°. A short intra-molecular C-H⋯N contact closes an S(6) ring. The nitro group is disordered over two orientations in a statistical ratio. In the crystal, weak C-H⋯O hydrogen bonds and very weak π-π stacking inter-actions [centroid-centroid separation = 3.9168 (17) Å] are observed.