PROTOCOL: Effectiveness of nutrition counselling for pregnant women in low- and middle-income countries to improve maternal, infant and child behavioural, nutritional and health outcomes: A systematic review.

The objective of this systematic review is to identify, appraise and synthesise the best available evidence on the effectiveness of nutritional counselling and education interventions on maternal, infant and child health outcomes, and assess the differences in effects across participants' PROGRESS+ characteristics. To achieve these objectives, we will aim to answer the following research questions: What is the effectiveness of nutrition counselling interventions for pregnant women in low- or middle-income countries on maternal, infant and child health outcomes? What are the impacts of nutrition counselling interventions on maternal, infant and child health outcomes across participants' PROGRESS+ characteristics?

Mineral- and vitamin-enhanced micronutrient powder reduces stunting in full-term low-birth-weight infants receiving nutrition, health, and hygiene education: a 2 × 2 factorial, cluster-randomized trial in Bangladesh.

BACKGROUND: The causes of stunting are complex but likely include prenatal effects, inadequate postnatal nutrient intake, and recurrent infections. Low-birth-weight (LBW) infants are at high risk of stunting. More than 25% of live births in low- and middle-income countries are at full term with low birth weight (FT-LBW). Evidence on the efficacy of specific interventions to enhance growth in this vulnerable group remains scant. OBJECTIVE: We investigated the independent and combined effects of a directed use of a water-based hand sanitizer (HS) and a mineral- and vitamin-enhanced micronutrient powder (MNP) (22 minerals and vitamins) to prevent infections and improve nutrient intake to reduce stunting in FT-LBW infants. DESIGN: The study was a prospective 2 × 2 factorial, cluster-randomized trial in 467 FT-LBW infants during 2 periods: from 0 to 5 mo postpartum (0-180 d postpartum) and from 6 to 12 mo postpartum (181-360 d postpartum) with the use of 48 clusters. All groups received the same general nutrition, health, and hygiene education (NHHE) at enrollment and throughout the 12 mo. Group assignments initially included the following 2 groups: no HS (control) group or HS from 0 to 5 mo postpartum. These assignments were followed by further divisions into the following 4 groups from 6 to 12 mo postpartum: 1) no HS and no MNP (control), 2) HS only, 3) MNP only, and 4) HS and MNP. RESULTS: When delivered in combination with NHHE, the use of an HS showed no additional benefit in reducing indicators of infection in the first or second half of infancy or the likelihood of stunting at 12 mo postpartum. FT-LBW infants who received the MNP (with or without the HS) were significantly less likely to be stunted at 12 mo than were controls (OR: 0.35; 95% CI: 0.15, 0.84; P = 0.017). CONCLUSIONS: The use of a mineral- and vitamin-enhanced MNP significantly reduced stunting in FT-LBW infants in this high-risk setting. The use of a water-based HS did not have an additive effect. This trial was registered at clinicaltrials.gov as NCT01455636.

A qualitative study exploring perceived barriers to infant feeding and caregiving among adolescent girls and young women in rural Bangladesh.

BACKGROUND: Infant feeding and caregiving by adolescent girls and young women in rural Bangladesh remains relatively understudied despite high potential vulnerability of younger mothers and their children due to poverty and high rates of early marriage and childbearing. This key knowledge gap may hamper the effectiveness of maternal, infant and child health interventions not specifically tailored to teenage mothers. This study aimed to narrow this gap by documenting key barriers to optimal infant and young child feeding and caregiving perceived by adolescent girls and young women in rural Bangladesh. METHODS: Focus group discussions and in-depth semi-structured interviews were conducted with 70 adolescent girls and young women participating in a community-based adolescent empowerment program in two rural regions of northwestern Bangladesh. Participants were stratified into three groups: unmarried, married without child, and married with child(ren). Thematic analysis was performed to elucidate dominant ideas regarding challenges with child feeding and caregiving across participant strata. RESULTS: Participants in all three strata and in both geographical regions attributed actual and anticipated caregiving difficulties to five major contextual factors: early marriage, maternal time allocation conflicts, rural life, short birth intervals, and poverty. Indications are that many girls and young women anticipate difficulties in feeding and caring for their future children from an early age, and often prior to motherhood. Participants articulated both perceived need and unmet demand for additional education in infant and young child feeding, childcare, and family planning techniques. CONCLUSIONS: Provision during adolescence of appropriate education, services and financial aid to support best practices for infant feeding and childcare could significantly improve maternal self-efficacy, mental health, nutrition security and young childcare, nutrition and health in rural Bangladesh. Lessons learned can be applied in future programs aimed at supporting adolescent women along a continuum of care.

Food Insecurity Mediates the Effect of a Poverty-Alleviation Program on Psychosocial Health among the Ultra-Poor in Bangladesh.

BACKGROUND: Poor psychosocial health is a major global burden. A challenge to improving psychosocial health is that its associations with risk factors are complicated, inadequately understood, and difficult to modify, and/or require action outside the health sector. OBJECTIVE: We capitalized on the quasi-experimental assignment of a poverty-alleviation program for the ultra-poor in Bangladesh to investigate how this program affected 2 aspects of psychosocial health; distress, (i.e., the negative cognitive appraisal of stress) and subjective well-being (i.e., satisfaction with domains of life), and the importance of food insecurity as a mediator relative to other stressors and economic status. METHODS: The study was conducted in 3 northern districts of Bangladesh where the program operated. The ultra-poor households were selected through a multistage selection process. The economically better-off households were excluded during the process and included as study controls. The program supported women by providing income-earning opportunities, strengthening sociopolitical livelihood, and building self-awareness and self-confidence. Data were collected in 2006 from 209 women on demography, psychosocial health, and stressors (i.e., domestic violence, food insecurity, economic status, perceived economy, and emotional social constraints). Data collected in 2002 from the same individuals were used to control for the baseline differences between groups. By using path analysis we showed the direct and indirect effects of the program on distress and well-being. RESULTS: The program positively affected psychosocial health by alleviating stressors. The indirect effect of the program contributed 74% in reducing distress and 30% in improving well-being. Food insecurity was by far the most important mediator, explaining 50% of indirect effect on distress and 66% of the indirect effect on well-being. CONCLUSION: Food insecurity is modifiable and an appropriate target for poverty-alleviation and agricultural programs. These findings suggest programmatic and policy attention to the social dimensions of poor psychosocial health, particularly to food insecurity as a central cause.

Knowledge, attitudes and perceptions on infant and young child nutrition and feeding among adolescent girls and young mothers in rural Bangladesh.

Improved infant and young child feeding (IYCF) practices have the potential to improve child health and development outcomes in poorly resourced communities. In Bangladesh, approximately 60% of rural girls become mothers before the age of 18, but most interventions to improve IYCF practices target older mothers. We investigated the knowledge, attitudes and perceptions regarding IYCF among adolescent girls and young women aged 15-23 years old in two rural regions in north-west Bangladesh and identified the main points of concordance with, or mismatch to, key international IYCF recommendations. We compared qualitative data collected during interviews and focus groups with participants who were unmarried, married without a child and married with at least one child, and stratified by region. Qualitative indicators of concordance with international recommendations suggest that IYCF knowledge of participants was limited, irrespective of marriage or maternity. Young mothers in our study were no more knowledgeable about feeding practices than their nulliparous peers. Some participants were well aware of an IYCF recommendation (e.g. to exclusively breastfeed for 6 months), but their interpretation of the recommendation deviated from the intended public health message. Notions of insufficient or 'spoiled' breast milk, gender-based biases in feeding intentions and understandings of infant needs, and generational shifts in feeding practices were commonly reported. Conclusions are that female adolescence is a window of opportunity for improving health outcomes among future children, and increased investment in early education of adolescent girls regarding safe IYCF may be an effective strategy to promote and support improved infant feeding practices.

A program impact pathway analysis identifies critical steps in the implementation and utilization of a behavior change communication intervention promoting infant and child feeding practices in Bangladesh.

Mapping pathways of how interventions are implemented and utilized enables contextually grounded interpretation of results, differentiates poor design from poor implementation, and identifies factors that might influence the utilization of interventions. Few studies in nutrition have comprehensively examined the steps of implementation and utilization in behavior change communication (BCC) interventions, thus limiting the interpretation of variable impacts of BCC interventions. A program impact pathway (PIP) analysis was used to study a BCC intervention implemented in Bangladesh to improve infant and young child feeding (IYCF) practices. The PIP was developed through an iterative process with the program implementation team; the PIP then guided the choice of methods and tools. Using mixed methods, we reviewed the content of training materials for implementation staff, measured their IYCF knowledge (n = 100), observed their communication with mothers (n = 37), and examined factors influencing promotion of IYCF practices and their trial and adoption by mothers (n = 64). Implementation staff demonstrated good knowledge and maintained fidelity to the intervention to a large extent. Mothers identified them as their primary sources of information, and a majority of mothers tried recommended IYCF practices. Key facilitators included family support and availability of resources, whereas lack of time, maternal and family perceptions of age-appropriate feeding, and lack of resources were salient barriers to adopting recommended practices. Using a PIP analysis identified critical issues pertaining to implementation (e.g., the role of paid and volunteer staff) and utilization (e.g., resource and time constraints that require complementary interventions) and the need for further research and programmatic attention.

The WHO evidence-informed guideline development process and implications for vitamin and mineral research priorities: symposium rationale and summary.

The WHO evidence-informed guidelines provide recommendations to Member States and their partners on interventions with vitamins and minerals. Evidence gathered and synthesized through systematic reviews contributes to the development of these guidelines, a process that is dependent on the availability and quality of evidence. Although the guideline development process is stringently governed and supervised to maintain clarity and transparency, the lack of adequacy and specificity of available evidence poses limitations to the formulation of recommendations that can be easily applied for policy and program decision making in diverse contexts. The symposium created a space for dialogue among scientists and public health practitioners to improve the understanding of how evidence fulfills the needs and reflect on mechanisms by which policy and program guidance and priorities for research could be better informed by policy and program needs. Ultimately, programmatic success depends not only on identifying efficacious agents but ensuring effective delivery to those with the potential to respond. To do this, we must understand the rationale for recommending interventions, the biological pathways by which interventions work, delivery systems required to make efficacious interventions work, and other contextual factors that might limit or facilitate successful implementation.

Effect of poverty reduction program on nutritional status of the extreme poor in Bangladesh.

BACKGROUND: Poverty alleviation programs for the extreme poor improve participants' economic status and may impact other important outcomes that are seldom evaluated. A program targeted to the extreme poor by BRAG, a development organization in Bangladesh, has been successful in significantly alleviating extreme poverty. OBJECTIVE: We hypothesized that the program also improved the nutritional status of women and preschool children. METHODS: A nonequivalent control, pre- and posttest quasi-experimental design that was longitudinal at the village level was used to test the hypotheses. Data were collected from a random sample of 4,131 children and 3,551 women from 3,409 households in 159 villages of 3 northern districts of Bangladesh in 2002 and 2006. Linear mixed random-intercept models accounted for clustering effects and potential confounders. RESULTS: The weight-for-height of children between 24 and 35 months of age from program households was significantly higher (p < .05) than that of children from control households. We found no significant differences between control and program households in three other growth and body-composition indicators in three other age categories of preschool children or in women. CONCLUSIONS: These results are important, as this is a large-scale program that has already been extended to more than half the country. The findings will contribute to judging the cost-benefit and cost-effectiveness of the program and in garnering support for the expansion of such programs.

Why does nutrition deteriorate rapidly among children under 2 years of age? Using qualitative methods to understand community perspectives on complementary feeding practices in Bangladesh.

BACKGROUND: Child undernutrition remains high in South Asian and sub-Saharan African countries. Rapid declines in nutritional status occur before the age of 2 years, particularly during the period of complementary feeding. Improving complementary feeding practices is a neglected area in nutrition programs. OBJECTIVE: To understand community perspectives on complementary feeding practices in order to inform the design of future interventions for improved complementary feeding. METHODS: From May through August 2009, data were collected in two rural locations and one urban location in Bangladesh through semistructured interviews, food attributes exercises, 24-hour dietary recalls, opportunistic observations, and trials of improved practices (TIPs). Key informant interviews and focus group discussions were also carried out among family members and community opinion leaders. RESULTS: Lay perceptions about complementary feeding differ substantially from international complementary feeding recommendations. A large proportion of children do not consume sufficient amounts of complementary foods to meet their energy and micronutrient needs. There was a gap in knowledge about appropriate complementary foods in terms of quality and quantity and strategies to convert family foods to make them suitable for children. Complementary feeding advice from family members, peers, and health workers, the importance given to feeding young children, and time spent by caregivers in feeding influenced the timing, frequency, types of food given, and ways in which complementary feeding occurred. CONCLUSIONS: Perceptions and practices related to complementary feeding need to be effectively addressed to improve the levels of child undernutrition. Lack of understanding of children's nutritional needs and insufficient time for feeding children are key barriers to complementary feeding.

A multiple-micronutrient-fortified beverage affects hemoglobin, iron, and vitamin A status and growth in adolescent girls in rural Bangladesh.

Adolescent girls have high nutrient needs and are susceptible to micronutrient deficiencies. The objective of this study was to test the effect of a multiple-micronutrient-fortified beverage on hemoglobin (Hb) concentrations, micronutrient status, and growth among adolescent girls in rural Bangladesh. A total of 1125 girls (Hb > or = 70 g/L) enrolled in a randomized, double-blind, placebo-controlled trial and were allocated to either a fortified or nonfortified beverage of similar taste and appearance. The beverage was provided at schools 6 d/wk for 12 mo. Concentrations of Hb and serum ferritin (sFt), retinol, zinc, and C-reactive protein were measured in venous blood samples at baseline, 6 mo, and 12 mo. In addition, weight, height, and mid-upper arm circumference (MUAC) measurements were taken. The fortified beverage increased the Hb and sFt and retinol concentrations at 6 mo (P < 0.01). Adolescent girls in the nonfortified beverage group were more likely to suffer from anemia (Hb <120 g/L), iron deficiency (sFt <12 microg/L), and low serum retinol concentrations (serum retinol <0.70 micromol/L) (OR = 2.04, 5.38, and 5.47, respectively; P < 0.01). The fortified beverage group had greater increases in weight, MUAC, and BMI over 6 mo (P < 0.01). Consuming the beverage for an additional 6 mo did not further improve the Hb concentration, but the sFt level continued to increase (P = 0.01). The use of multiple-micronutrient-fortified beverage can contribute to the reduction of anemia and improvement of micronutrient status and growth in adolescent girls in rural Bangladesh.