Impact of a Homestead Food Production Program on Dietary Diversity: Seasonal and Annual Results from the Cluster-Randomized FAARM Trial in Sylhet, Bangladesh.

BACKGROUND: Rice-predominant diets are common in Bangladesh, leading to widespread nutritional deficiencies. The Food and Agricultural Approaches to Reducing Malnutrition (FAARM) cluster-randomized controlled trial in rural Sylhet, Bangladesh evaluated a homestead food production intervention implemented 2015-2018 through Helen Keller International, aiming to improve child growth. OBJECTIVES: We estimated the intervention's impact on women's and children's dietary diversity, a secondary trial objective. METHODS: We collected dietary diversity throughout the trial (March 2015 to June 2020) at multiple times each year using standard, United Nations-endorsed, self-reported measures for women (10-food group scale) and children (7-food group scale). We included 28,282 observations of 2701 women (out of 2705 enrolled) and 17,445 observations of their 3257 children (aged 6-37 mo) in 96 settlements, 48 of which received the intervention. We estimated the intervention's impact on dietary diversity by year of intervention, overall periods following the start of the intervention, and seasonally, using multilevel regression with the control group as the counterfactual, controlling for seasonality, baseline dietary diversity, and clustering by settlement and repeated measures. RESULTS: At baseline, approximately one-third of women and children consumed a minimally diverse diet. Over the entire intervention and postintervention period, women's and children's odds of consuming a minimally diverse diet nearly doubled (odds ratio [OR] 1.8, P < 0.001, for both). This benefit was barely present in the first year, increased in the second, and peaked in the last intervention year (OR 2.4 for women, OR 2.5 for children, both P < 0.001) before settling at around double the odds in postintervention years (P < 0.001). Dietary improvement was observed throughout the year for both women and children with incremental increases in nearly all food groups. CONCLUSIONS: The nutrition-sensitive agriculture intervention successfully increased dietary diversity in women and children, and these impacts persisted after the project closed, including during the early COVID 19 lockdown period. This trial was registered at clinicaltrials.gov as NCT02505711.

Diagnosing norms and norm change in rural Bangladesh: an exploration of gendered social norms and women's empowerment.

BACKGROUND: Gender-transformative public health programs often aim to address power inequities between men and women and promote women's empowerment. However, to achieve transformative change, it is necessary to first identify the underlying norms that perpetuate these power imbalances. The objective of our study was to use Bicchieri's theory of social norms and model of norm change to identify gendered norms and evidence of norm change amongst participants of the Food and Agricultural Approaches to Reducing Malnutrition (FAARM) trial in rural Sylhet Division, Bangladesh. METHODS: We conducted ten life history interviews, 16 key informant interviews, and four focus group discussions with women and men in communities within the FAARM study site in rural, north-eastern Bangladesh. We performed a thematic analysis as well as a relational analysis of the data. RESULTS: We found that social norms dictated the extent and ways in which women participated in household decisions, the locations they could visit, and their autonomy to use household resources. We also found evidence of changes to gendered social norms over time and the desire amongst some men and women to abandon restrictive norms. Certain intersecting factors, such as education and employment, were identified as facilitators and barriers to women's empowerment and the related gendered expectations. CONCLUSIONS: Our findings corroborate existing norms literature, which highlights the strong role social norms play in influencing women's empowerment and behaviour. Our study provides an example of rigorous qualitative methodology that others may follow to assess gendered social norms that can be targeted for transformative change.

Effect of a Homestead Food Production and Food Hygiene Intervention on Biomarkers of Environmental Enteric Dysfunction in Children Younger Than 24 Months in Rural Bangladesh: A Cluster-Randomized Controlled Trial.

Poor sanitation and hygiene practices and inadequate diets can contribute to environmental enteric dysfunction (EED). We evaluated the impact of a combined homestead food production and food hygiene intervention on EED biomarkers in young children in rural Bangladesh. The analysis was conducted within the Food and Agricultural Approaches to Reducing Malnutrition (FAARM) cluster-randomized trial in Sylhet, Bangladesh. The FAARM trial enrolled 2,705 married women and their children younger than 3 years of age in 96 settlements (geographic clusters): 48 intervention and 48 control. The 3-year intervention (2015-2018) included training on gardening, poultry rearing, and improved nutrition practices and was supplemented by an 8-month food hygiene behavior change component, implemented from mid-2017. We analyzed data on 574 children age 0 to 24 months with multilevel linear regression. We assessed fecal myeloperoxidase (MPO), neopterin (NEO), and alpha-1-antitrypsin (AAT) as biomarkers of EED, and serum C-reactive protein (CRP) and alpha-1-acid glycoprotein (AGP) as biomarkers of systemic inflammation, using ELISA. There was no intervention effect on NEO, AAT, CRP, and AGP concentrations, but, surprisingly, MPO levels were increased in children of the intervention group (0.11 log ng/mL; 95% CI, 0.001-0.22). This increase was greater with increasing child age and among intervention households with poultry that were not kept in a shed. A combined homestead food production and food hygiene intervention did not decrease EED in children in our study setting. Small-scale poultry rearing promoted by the intervention might be a risk factor for EED.

Effect of a Homestead Food Production Program on the Prevalence of Diarrhea and Acute Respiratory Infection in Children in Sylhet, Bangladesh: A Cluster-Randomized Controlled Trial.

Diarrhea and respiratory illness are leading causes of mortality and morbidity among young children. We assessed the impact of a homestead food production intervention on diarrhea and acute respiratory infection (ARI) in children in Bangladesh, secondary outcomes of the Food and Agricultural Approaches to Reducing Malnutrition (FAARM) cluster-randomized trial. The trial enrolled 2,705 married women and their children 3 years or younger in 96 rural settlements (geographic clusters) in Sylhet Division, Bangladesh. The intervention promoted home gardening and poultry rearing alongside child nutrition and health counseling over 3 years (2015-2018). An 8-month food hygiene behavior change component using emotional drivers was delivered beginning in mid-2017. Caregiver-reported diarrhea and symptoms of ARI in the week preceding the survey were recorded every 2 months. We analyzed 32,460 observations of 3,276 children over 4 years and found that 3.9% of children had diarrhea and 3.4% had an ARI in the prior 7 days. There was no overall effect of the intervention on 7-day diarrhea period prevalence (odds ratio [OR], 0.92; 95% CI, 0.71-1.19), diarrhea point prevalence (OR, 1.03; 95% CI, 0.78-1.36), or 7-day ARI period prevalence (OR, 1.18; 95% CI, 0.88-1.60). There was no impact on diarrhea severity or differences in health-seeking behaviors. Our findings suggest that this homestead food production program was insufficient to reduce morbidity symptoms among children in a rural setting. More comprehensive water, sanitation, and hygiene measures, and behavioral recommendations may be needed to achieve impacts on child health.

Impact of a Homestead Food Production program on poultry rearing and egg consumption: A cluster-randomized controlled trial in Bangladesh.

Women and children in Bangladesh face high levels of micronutrient deficiencies from inadequate diets. We evaluated the impact of a Homestead Food Production (HFP) intervention on poultry production, as a pathway outcome, and women's and children's egg consumption, as secondary outcomes, as part of the Food and Agricultural Approaches to Reducing Malnutrition cluster-randomized trial in Sylhet division, Bangladesh. The 3-year intervention (2015-2018) promoted home gardening, poultry rearing, and nutrition counseling. We randomly allocated 96 clusters to intervention (48 clusters; 1337 women) or control (48 clusters; 1368 women). Children < 3 years old born to participants were enrolled during the trial. We analyzed poultry production indicators, measured annually, and any egg consumption (24-h recall), measured every 2-6 months for women and their children. We conducted intention-to-treat analyses using mixed-effects logistic regression models with repeat measures, with minimal adjustment to increase precision. Poultry ownership increased by 16% points (pp) and egg production by 13 pp in the final intervention year. The intervention doubled women's odds of egg consumption in the final year (Odds Ratio [OR]: 2.31, 95% CI: 1.68-3.18), with positive effects sustained 1-year post-intervention (OR: 1.58, 95% CI: 1.16-2.15). Children's odds of egg consumption were increased in the final year (OR: 3.04, 95% CI: 1.87-4.95). Poultry ownership was associated with women's egg consumption, accounting for 12% of the total intervention effect, but not with children's egg consumption. Our findings demonstrate that an HFP program can have longer-term positive effects on poultry production and women's and children's diets.

Key Food Hygiene Behaviors to Reduce Microbial Contamination of Complementary Foods in Rural Bangladesh.

Microbial contamination of complementary foods puts young children at risk of developing intestinal infections and could be reduced by improved handwashing and food hygiene practices. We aimed to identify which promoted food hygiene practices are associated with reduced complementary food contamination in a rural population in Bangladesh. We collected cross-sectional data on reported and observed maternal food hygiene behaviors and measured Escherichia coli counts as an indicator of microbial contamination in complementary food samples from 342 children of women enrolled in the Food and Agricultural Approaches to Reducing Malnutrition trial in Sylhet, Bangladesh. We used multivariable logistic regression to examine associations of food hygiene behaviors with food contamination. Approximately 46% of complementary food samples had detectable levels of E. coli. Handwashing with soap at critical times and fresh preparation of food before feeding were strongly associated with reduced odds of food sample contamination (odds ratio [OR]: 0.8, 95% confidence interval [CI]: 0.6-0.9 and OR: 0.3, 95% CI: 0.1-0.7, respectively); in contrast, there was no or only weak evidence that reheating of stored food, safe food storage, and cleanliness of feeding utensils reduced contamination. Reduction in food contamination could be more than halved only when several food hygiene behaviors were practiced in combination. In conclusion, single food hygiene practices showed limited potential and a combined practice of multiple food hygiene behaviors may be needed to achieve a substantial reduction of complementary food contamination.

Design, delivery, and determinants of uptake: findings from a food hygiene behavior change intervention in rural Bangladesh.

BACKGROUND: Microbial food contamination, although a known contributor to diarrheal disease and highly prevalent in low-income settings, has received relatively little attention in nutrition programs. Therefore, to address the critical pathway from food contamination to infection to child undernutrition, we adapted and integrated an innovative food hygiene intervention into a large-scale nutrition-sensitive agriculture trial in rural Bangladesh. In this article, we describe the intervention, analyze participation and uptake of the promoted food hygiene behaviors among intervention households, and examine the underlying determinants of behavior adoption. METHODS: The food hygiene intervention employed emotional drivers, engaging group activities, and household visits to improve six feeding and food hygiene behaviors. The program centered on an 'ideal family' competition. Households' attendance in each food hygiene session was documented. Uptake of promoted behaviors was assessed by project staff on seven 'ideal family' indicators using direct observations of practices and spot checks of household hygiene conditions during household visits. We used descriptive analysis and mixed-effect logistic regression to examine changes in household food hygiene practices and to identify determinants of uptake. RESULTS: Participation in the food hygiene intervention was high with more than 75% attendance at each session. Hygiene behavior practices increased from pre-intervention with success varying by behavior. Safe storage and fresh preparation or reheating of leftover foods were frequently practiced, while handwashing and cleaning of utensils was practiced by fewer participants. In total, 496 of 1275 participating households (39%) adopted at least 5 of 7 selected practices in all three assessment rounds and were awarded 'ideal family' titles at the end of the intervention. Being an 'ideal family' winner was associated with high participation in intervention activities [adjusted odds ratio (AOR): 11.4, 95% CI: 5.2-24.9], highest household wealth [AOR: 2.3, 95% CI: 1.4-3.6] and secondary education of participating women [AOR: 2.2, 95% CI: 1.4-3.4]. CONCLUSION: This intervention is an example of successful integration of a behavior change food hygiene component into an existing large-scale trial and achieved satisfactory coverage. Future analysis will show if the intervention was able to sustain improved behaviors over time and decrease food contamination and infection.

Women's fasting habits and dietary diversity during Ramadan in rural Bangladesh.

Little is known about fasting practices and dietary changes during Ramadan in low- and lower-middle-income countries. Although pregnant women are exempt from fasting, they may still fast. This is of interest as dietary habits during pregnancy may affect the development of the unborn child. In a community-based sample of young women in rural Sylhet division, Bangladesh, we described fasting practices and beliefs (n = 852). We also examined reported food group consumption and minimally adequate dietary diversity for women (MDD-W) by Ramadan occurrence (n = 1,895) and by fasting adherence (n = 558) using logistic regression with Hindu women as a seasonal control. During Ramadan in 2018, 78% of pregnant Muslim women fasted every day. Over 80% of Muslim women believe that they should fast during pregnancy and over 50% expect positive health effects on the mother and the unborn child. We found strong evidence that Muslim women have more diverse diets during Ramadan, with higher odds of MDD-W (OR [95% CI]: 5.0 [3.6, 6.9]) and increased consumption of pulses, dairy, fruit, and large fish. Dietary diversity increased to a lesser extent on non-fasting days during Ramadan. Ramadan appears to improve dietary quality in both fasting and non-fasting Muslim women in a rural population in Bangladesh. These results help to interpret findings from studies on Ramadan during pregnancy on later-life outcomes and thus contribute to a better understanding of intrauterine influences of maternal nutrition on healthy child development.

How to prevent and address safeguarding concerns in global health research programmes: practice, process and positionality in marginalised spaces.

Safeguarding is rapidly rising up the international development agenda, yet literature on safeguarding in related research is limited. This paper shares processes and practice relating to safeguarding within an international research consortium (the ARISE hub, known as ARISE). ARISE aims to enhance accountability and improve the health and well-being of marginalised people living and working in informal urban spaces in low-income and middle-income countries (Bangladesh, India, Kenya and Sierra Leone). Our manuscript is divided into three key sections. We start by discussing the importance of safeguarding in global health research and consider how thinking about vulnerability as a relational concept (shaped by unequal power relations and structural violence) can help locate fluid and context specific safeguarding risks within broader social systems. We then discuss the different steps undertaken in ARISE to develop a shared approach to safeguarding: sharing institutional guidelines and practice; facilitating a participatory process to agree a working definition of safeguarding and joint understandings of vulnerabilities, risks and mitigation strategies and share experiences; developing action plans for safeguarding. This is followed by reflection on our key learnings including how safeguarding, ethics and health and safety concerns overlap; the challenges of referral and support for safeguarding concerns within frequently underserved informal urban spaces; and the importance of reflective practice and critical thinking about power, judgement and positionality and the ownership of the global narrative surrounding safeguarding. We finish by situating our learning within debates on decolonising science and argue for the importance of an iterative, ongoing learning journey that is critical, reflective and inclusive of vulnerable people.

BRAC's experience in scaling-up MNP in Bangladesh.

Despite progress in health status and achievements in Millennium Development Indicators, Bangladesh presents a gloomy scenario for nutrition. In 2009, BRAC (formerly known as Bangladesh Rural Advancement Committee) has begun to implement a community-based approach of Alive & Thrive with Family Health International 360, aiming to reduce undernutrition among children under two by promoting exclusive breastfeeding and appropriate complementary feeding practices. To address anemia and other micronutrient deficiencies, home-fortification with micronutrient powders (MNP) has been promoted among under-fives across Bangladesh along with the Global Alliance for Improved Nutrition (GAIN). BRAC's frontline community health workers play a critical role in promoting micronutrient powders with better feeding practices. Over the years, improvements have been observed in the intervention areas: exclusive breastfeeding rose from 49% to 83% of children (0-6 months), 86% of children received complementary feeding at 6-8 months with about two/thirds being fed the recommended number of times; and 70% of children (6-59 months) adhered to MNP use, ie consumption of 1 sachet per day in the past 60 days. However, many challenges are still observed in traditional feeding practices, along with limited skills of community health workers and households' poor access to quality food, necessitating constant interactions between caregivers, mothers-in-law and fathers with the frontline workers. Maintaining the supply chain of micronutrient powders and a visible and convincing change in nutritional status of children are key success factors. The partnerships between BRAC, GAIN and Renata, the producer of MNP in Bangladesh, have given birth to a home-fortification model that can deliver impact at scale.