Effects of an integrated poultry value chain, nutrition, gender and WASH intervention (SELEVER) on hygiene and child morbidity and anthropometry in Burkina Faso: A secondary outcome analysis of a cluster randomised trial.

Nutrition-sensitive agriculture programmes have the potential to improve child nutrition outcomes, but livestock intensification may pose risks related to water, sanitation and hygiene (WASH) conditions. We assessed the impact of SELEVER, a nutrition- and gender-sensitive poultry intervention, with and without added WASH focus, on hygiene practices, morbidity and anthropometric indices of nutrition in children aged 2-4 years in Burkina Faso. A 3-year cluster randomised controlled trial was implemented in 120 villages in 60 communes (districts) supported by the SELEVER project. Communes were randomly assigned using restricted randomisation to one of three groups: (1) SELEVER intervention (n = 446 households); (2) SELEVER plus WASH intervention (n = 432 households); and (3) control without intervention (n = 899 households). The study population included women aged 15-49 years with an index child aged 2-4 years. We assessed the effects 1.5-years (WASH substudy) and 3-years (endline) post-intervention on child morbidity and child anthropometry secondary trial outcomes using mixed effects regression models. Participation in intervention activities was low in the SELEVER groups, ranging from 25% at 1.5 years and 10% at endline. At endline, households in the SELEVER groups had higher caregiver knowledge of WASH-livestock risks (∆ = 0.10, 95% confidence interval [CI] [0.04-0.16]) and were more likely to keep children separated from poultry (∆ = 0.09, 95% CI [0.03-0.15]) than in the control group. No differences were found for other hygiene practices, child morbidity symptoms or anthropometry indicators. Integrating livestock WASH interventions alongside poultry and nutrition interventions can increase knowledge of livestock-related risks and improve livestock-hygiene-related practices, yet may not be sufficient to improve the morbidity and nutritional status of young children.

A Community-Based Early Childhood Development Center Platform Promoting Diversified Diets and Food Production Increases the Mean Probability of Adequacy of Intake of Preschoolers in Malawi: A Cluster Randomized Trial.

BACKGROUND: Young children in Malawi consume low-quality diets lacking micronutrients critical for their development. OBJECTIVE: To evaluate the impact of an agriculture and nutrition behavior change communication (BCC) intervention implemented through community-based childcare centers on the nutrient adequacy of diets of children living in food-insecure settings in Malawi. METHODS: A cluster randomized trial was undertaken in 60 community-based childcare centers, including 1248 children aged 3-6 y. Nutrient intakes were estimated using interactive, multipass 24-h recall. Dietary adequacy was estimated through the probability of adequacy (PA) and mean probability of adequacy (MPA) of 11 micronutrients. Impacts were assessed by difference-in-difference (DID) estimates, adjusted for geographic clustering and child age and sex. RESULTS: Intervention groups were similar for most baseline characteristics. Loss to follow-up was low (7% over a 12-mo period) and participation in the intervention was high (>90% enrollment and 80% attendance during the 5 d before the survey). Positive impacts were found for the PA of several individual micronutrient intakes: vitamin A [DID: 9 percentage points (pp), SE 3 pp], vitamin C (14 pp, SE 3 pp), riboflavin (11 pp, SE 3 pp), zinc (8 pp, SE 3 pp), and for the MPA for the 11 nutrients considered (5 pp, SE 1 pp). These impacts were driven by effects on younger children (aged 3-4 y). CONCLUSIONS: Using a preschool platform to implement a nutrition-sensitive BCC intervention is an effective strategy to improve the adequacy of micronutrient intake of preschool children in food-insecure settings. The trial was registered at ISCRCTN as ISCRCTN96497560.

Poultry husbandry, water, sanitation, and hygiene practices, and child anthropometry in rural Burkina Faso.

Poultry production in low income countries provides households with nutrient-rich meat and egg products, as well as cash income. However, traditional production systems present potential health and nutrition risks because poultry scavenging around household compounds may increase children's exposure to livestock-related pathogens. Data from a cross-sectional survey were analysed to examine associations between poultry, water, sanitation, and hygiene practices, and anthropometric indicators in children (6-59 months; n = 3,230) in Burkina Faso. Multilevel regression was used to account for the hierarchical nature of the data. The prevalence of stunting and wasting in children 6-24 months was 19% and 17%, respectively, compared with a prevalence of 26% and 6%, respectively, in children 25-60 months. Over 90% of households owned poultry, and chicken faeces were visible in 70% of compounds. Caregivers reported that 3% of children consumed eggs during a 24-hr recall. The presence of poultry faeces was associated with poultry flock size, poultry-husbandry and household hygiene practices. Having an improved water source and a child visibly clean was associated with higher height-for-age z scores (HAZ). The presence of chicken faeces was associated with lower weight-for-height z scores, and no associations were found with HAZ. Low levels of poultry flock size and poultry consumption in Burkina Faso suggest there is scope to expand production and improve diets in children, including increasing chicken and egg consumption. However, to minimize potential child health risks associated with expanding informal poultry production, research is required to understand the mechanisms through which cohabitation with poultry adversely affects child health and design interventions to minimize these risks.

Using a Community-Based Early Childhood Development Center as a Platform to Promote Production and Consumption Diversity Increases Children's Dietary Intake and Reduces Stunting in Malawi: A Cluster-Randomized Trial.

Background: Children in Malawi face nutritional risks related to low-quality diets and chronic malnutrition. Objective: This study evaluated the impact of a 1-y early childhood development (ECD) center-based agriculture and nutrition intervention aimed at improving household production diversity, maternal knowledge on child nutrition and feeding practices, and children's diets and anthropometric measures. Methods: A longitudinal cluster-randomized controlled trial was implemented in 60 community-based childcare centers (CBCCs), covering 1248 preschool children (aged 36-72 mo) and 304 younger siblings (aged 6-24 mo). CBCCs were randomly assigned to 1) a control group providing the Save the Children's ECD program or 2) a treatment group providing a standard ECD program with additional activities to improve nutritious food production and behavior change communication to improve diets and care practices for young children. Primary outcomes were household production and production diversity, preschooler enrollment and attendance, and dietary intake measured by quantitative 24-h recall and minimum diet diversity for younger siblings. Secondary outcomes included anthropometric measures for preschoolers and younger siblings, child development scores for preschoolers, and women's asset ownership and time use (the latter 2 are not discussed in this article). We used difference-in-difference (DID) estimates to assess impacts. Results: Compared with the control group, preschool children in the intervention group had greater increases in nutrient intakes and in dietary diversity. No impacts on anthropometric measures were seen in preschoolers. Younger siblings in the intervention group had greater increases in height-for-age z scores than did children in the control group (DID: 0.44; P < 0.05) and greater reductions in the prevalence of stunting (DID: -17 percentage points; P < 0.05). The plausibility of the impact on growth in younger siblings was supported by effects along program impact pathways, including production of nutritious foods, caregiver knowledge, and dietary diversity. Conclusion: Implementing an integrated agriculture and nutrition intervention through an ECD platform benefited children's diets and reduced stunting among younger siblings of targeted preschoolers. This trial was registered on the ISRCTN registry as ISCRCTN96497560.

Improving child nutrition and development through community-based childcare centres in Malawi - The NEEP-IE study: study protocol for a randomised controlled trial.

BACKGROUND: The Nutrition Embedded Evaluation Programme Impact Evaluation (NEEP-IE) study is a cluster randomised controlled trial designed to evaluate the impact of a childcare centre-based integrated nutritional and agricultural intervention on the diets, nutrition and development of young children in Malawi. The intervention includes activities to improve nutritious food production and training/behaviour-change communication to improve food intake, care and hygiene practices. This paper presents the rationale and study design for this randomised control trial. METHODS: Sixty community-based childcare centres (CBCCs) in rural communities around Zomba district, Malawi, were randomised to either (1) a control group where children were attending CBCCs supported by Save the Children's Early Childhood Health and Development (ECD) programme, or (2) an intervention group where nutritional and agricultural support activities were provided alongside the routine provision of the Save the Children's ECD programme. Primary outcomes at child level include dietary intake (measured through 24-h recall), whilst secondary outcomes include child development (Malawi Development Assessment Tool (MDAT)) and nutritional status (anthropometric measurements). At household level, primary outcomes include smallholder farmer production output and crop-mix (recall of last production season). Intermediate outcomes along theorised agricultural and nutritional pathways were measured. During this trial, we will follow a mixed-methods approach and undertake child-, household-, CBCC- and market-level surveys and assessments as well as in-depth interviews and focus group discussions with project stakeholders. DISCUSSION: Assessing the simultaneous impact of preschool meals on diets, nutrition, child development and agriculture is a complex undertaking. This study is the first to explicitly examine, from a food systems perspective, the impact of a preschool meals programme on dietary choices, alongside outcomes in the nutritional, child development and agricultural domains. The findings of this evaluation will provide evidence to support policymakers in the scale-up of national programmes. TRIAL REGISTRATION: ISRCTN registry, ID: ISRCTN96497560 . Registered on 21 September 2016.

Lean-Season Food Transfers Affect Children's Diets and Household Food Security: Evidence from a Quasi-Experiment in Malawi.

Background: There is evidence that social transfers increase food consumption, improving the quantity and quality of food consumed by poor households. Questions remain on how to improve the effectiveness of social programs.Objective: The aim was to assess the impact of a lean-season food transfer on household food security, diet, and nutrition status of young children during the lean season in Malawi and to understand processes through which transfers operated.Methods: This was a longitudinal, quasi-experimental study based on 2 survey rounds in the Zomba district in Malawi. Data were collected from 60 communities randomly selected among food-insecure villages. Twenty households were randomly selected for interviews within each community. Study outcomes included household expenditures and food consumption (measured by using 7-d recall) and child-level dietary diversity (measured by using 24-h recall) and nutritional status (anthropometric measurements). We followed a mixed-methods approach involving child- and household-level assessments, as well as interviews with community stakeholders. We estimated program impact by combining propensity score matching and difference-in-difference methods.Results: The per capita effect of food transfers on food expenditure was estimated at 36 Malawian kwachas/d, corresponding to an increase of 19% from baseline. There was evidence of increased iron availability in household intake. Highly significant effects were found on children's dietary diversity score, corresponding to an increase of 15%, as well as a positive effect on weight-for-height z scores (WHZs) of >0.25 SDs. Effects on food expenditure and dietary diversity were robust to alternative matching specifications, although the effect on WHZs was not. Examination of the targeting of the transfer showed evidence of large errors of inclusion and exclusion.Conclusion: During the lean season in food-insecure settings, where important declines in food insecurity, diet quality, and nutrition status are present, food transfers may have a protective effect on household food security and diets of young children.