Text messages to improve young child diets: Results from a cluster-randomized controlled trial in Kanchanpur, Nepal.

The objective of this study was to test whether adding a text message campaign about the importance of eating eggs and other nutrition-related behaviours to an on-going package of large-scale, diverse social and behaviour change interventions would improve four types of nutrition-related knowledge and behaviour outcomes: child diets (egg consumption as the primary outcome), maternal diets, maternal nutrition knowledge, and maternal participation in additional interventions. The cluster-randomized controlled trial involved a repeat cross-sectional design, recruiting families with children 12-23 months of age at baseline and endline in one plains district of Nepal. Throughout the 1000-day period, 51 text messages were sent to each household at specific time points to reinforce ideal diets and other nutrition-related practices and promote engagement with community health workers and other intervention platforms. The primary outcome was egg consumption and dietary diversity among young children. We found no population-level effect. Some evidence supports that for those who received and opened the SMS intervention, it improved child egg consumption (odds ratio [OR]: 1.41, 95% confidence interval [CI]: 1.03-1.93), child minimum dietary diversity (OR: 1.36, 95% CI: 1.07-1.73), child dietary diversity scores (ß: 0.15, 95% CI: 0.01-0.24), as well as maternal IYCF knowledge (ß: 0.21, 95% CI: 0.08-0.35), participation in health mothers' group meetings (OR: 3.03, 95% CI: 1.91-4.84) and Bhanchhin Aama listenership (OR: 1.36, 95% CI: 1.07-1.73). This study highlights the importance of more research to understand the effectiveness of emerging digital interventions for behaviour change among specific populations, to facilitate nuanced targeting to those who can best benefit from these investments. Registered at clinicaltrials.gov with identifier NCT03926689.

Impact of Suaahara, an at-scale multisectoral nutrition programme, on health workers' maternal and child health, and nutrition knowledge and skills in Nepal.

Suaahara, an at-scale multisectoral nutrition programme in Nepal, aimed to advance knowledge and skills of frontline health workers to improve the quality of nutrition and health services at health facility and community levels. This study assessed the impact of Suaahara interventions on knowledge and skills of health facility workers and Female Community Health Volunteers (FCHVs). The study used a quasi-experimental design in which four Suaahara intervention districts were compared with pair-matched comparison districts. One health facility worker and three FCHVs from each survey cluster were included. Baseline survey consisted of 93 health facility workers (2015) and 118 FCHVs (2012), and endline survey (2022) consisted of 40 health facility workers and 120 FCHVs. Difference-in-differences regression models employing intent-to-treat analysis, accounting for clustering at the district level, assessed the impact of intervention. The intervention, relative to comparison, had no effect on health facility workers' knowledge. There was a positive effect, however, on FCHVs' knowledge in intervention relative to comparison areas on exclusive breastfeeding, timing of introduction of complementary feeding, sick child feeding and growth monitoring and promotion (GMP) for children under 2 years. Health facility workers and FCHVs in intervention versus comparison districts had higher endline scores for skills related to measuring the weight of children and pregnant women, measuring the height/length of children, conducting GMP for children under 2 years and identifying malnourished children. Suaahara interventions improved the capacity of health workers, particularly nutrition-related knowledge among FCHVs and GMP-related skills of both health facility workers and FCHVs.

The costs of Suaahara II, a complex scaled-up multisectoral nutrition programme in Nepal.

Limited evidence exists on the costs of scaled-up multisectoral nutrition programmes. Such evidence is crucial to assess intervention value and affordability. Evidence is also lacking on the opportunity costs of implementers and participants engaging in community-level interventions. We help to fill this gap by estimating the full financial and economic costs of the United States Agency for International Development-funded Suaahara II (SII) programme, a scaled-up multisectoral nutrition programme in Nepal (2016-2023). We applied a standardized mixed methods costing approach to estimate total and unit costs over a 3.7-year implementation period. Financial expenditure data from national and subnational levels were combined with economic cost estimates assessed using in-depth interviews and focus group discussions with staff, volunteers, community members, and government partners in four representative districts. The average annual total cost was US$908,948 per district, with economic costs accounting for 47% of the costs. The annual unit cost was US$132 per programme participant (mother in the 1000-day period between conception and a child's second birthday) reached. Annual costs ranged from US$152 (mountains) to US$118 (plains) per programme participant. Personnel (63%) were the largest input cost driver, followed by supplies (11%). Community events (29%) and household counselling visits (17%) were the largest activity cost drivers. Volunteer cadres contributed significant time to the programme, with female community health volunteers spending a substantial amount of time (27 h per month) on SII activities. Multisectoral nutrition programmes can be costly, especially when taking into consideration volunteer and participant opportunity costs. This study provides much-needed evidence of the costs of scaled-up multisectoral nutrition programmes for future comparison against benefits.

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.

Text messages to improve child diets: Formative research findings and protocol of a randomised controlled trial in Nepal.

Given the role of malnutrition in childhood morbidity and mortality, the prioritisation of maternal and child nutrition programmes has grown significantly in the 21st century. Policies and programmes aim to improve infant and young child feeding, but questions persist about the most effective combination of interventions to achieve desired behaviour change. There is increasing interest in mobile-based interventions globally, but scant evidence exists to guide donors, policymakers and programme implementers on their effectiveness. Formative research was conducted to assess the feasibility and acceptance of text message-based interventions and to guide the final design of the text message intervention. This protocol is for a cluster-randomised controlled trial to test the effectiveness of adding text messaging to other ongoing SBC interventions to promote egg consumption, dietary diversity and other ideal dietary practices, particularly among children 12-23 months of age in Kanchanpur, Nepal. The trial findings will contribute to the emerging body of evidence on the effectiveness of using text messages for behaviour change, specifically for young child dietary outcomes in South Asia. Recent studies have suggested that mobile-based interventions alone may be insufficient but valuable when added to other social and behavioural interventions; this trial will help to provide evidence for or against this emerging theory. This trial was registered at ClinicalTrials.gov on 11 March 2019 (ID: NCT03926689) and has been updated twice.

Gendered Intrahousehold Bargaining Power is Associated with Child Nutritional Status in Nepal.

BACKGROUND: Women's intrahousehold bargaining power is an important determinant of child nutrition in Nepal, but a better understanding is needed on how men's bargaining power is related to child nutrition. OBJECTIVES: We examined the relation of women's and men's household bargaining power with child height-for-age z score (HAZ). METHODS: We analyzed cross-sectional data from 2012, collected as an impact evaluation baseline of the Suaahara 1 program. A subsample of households with data on women's and men's intrahousehold bargaining power (n = 2170) with children aged 0-59 mo across Nepal was considered for this analysis. Intrahousehold bargaining power consisted of 4 domains: 1) ownership and control of assets, 2) social participation, 3) time allocation to work activities (workload), and 4) household decision-making control. Using multilevel methods, we analyzed associations between HAZ and 1) women's bargaining power, 2) men's bargaining power, and 3) women's and men's bargaining power, adjusted for individual- and household-level confounding factors and clustering. RESULTS: Women's ownership and control of assets was positively associated with HAZ when women's and men's domains were modeled together (ß: 0.0597, P = 0.026). Men's social participation was positively associated with HAZ in the men's model (ß: 0.233, P < 0.001) and the model with women's and men's domains (ß: 0.188, P = 0.001). Women's workload was negatively associated with HAZ in the women's model (ß: -0.0503, P = 0.014) and in the model with women's and men's domains (ß: -0.056, P = 0.008). Household decision making for women (ß: -0.0631, P = 0.007) and for men (ß: -0.0546, P = 0.017) were negatively associated with HAZ in the gender-specific models. Women's social participation, men's ownership and control of assets, and men's workload were not associated with HAZ. CONCLUSIONS: Women's workload and ownership and control of assets and men's social participation may be important in improving child HAZ in Nepal. Nutrition interventions should address women's intrahousehold bargaining power and promote men's social engagement.

Introduction: A family systems approach to promote maternal, child and adolescent nutrition.

In all cultures, women and children are embedded in family systems that determine roles, relationships, patterns of communication and authority between family members. Especially in non-western societies, maternal and child nutrition practices are determined not only by the biological parents but also by other influential family members. Most maternal and child nutrition research and interventions do not consider the constellation of family roles and influence on women and children and continue to focus on the mother-child dyad and individual knowledge, attitudes and practices. There is growing agreement on the need to adopt an ecological framework to address public health issues, including those dealing with maternal and child nutrition. This special issue presents examples of research from a variety of settings that employed an ecological, family systems approach either to investigate maternal, child or adolescent nutrition issues or to design interventions that engaged various actors within family settings. These 11 articles contribute to a growing body of evidence supporting the relevance of a wider family systems perspective for nutrition research and interventions. Key themes across studies include the limitations of using a nuclear family model for research and intervention design, the need for formative research that comprehensively explores family systems, increasing recognition of the extensive involvement and support provided by grandmothers, and the importance of engaging men in culturally appropriate ways based on community dialogue and women's perspectives. Future maternal and child nutrition research and interventions can be strengthened by systems thinking that acknowledges that individuals are situated within family and community systems.

Associations between parents' exposure to a multisectoral programme and infant and young child feeding practices in Nepal.

In Nepal, an at-scale, multisectoral programme-Suaahara (2011-2023)-aims to improve nutrition behaviours. Suaahara II (2016-2023) transitioned from a mother/child dyad focus to explicitly targeting all family members. Evidence is scant, however, regarding how exposure by men to social and behaviour change interventions relates to nutrition outcomes. This study uses a 2019 cross-sectional monitoring dataset to test associations between maternal and male household head exposure to Suaahara II interventions (interacting with a frontline worker, participating in a community event or listening to the Bhanchhin Aama radio programme) and adoption of three infant and young child feeding practices: minimum dietary diversity, minimum acceptable diet and sick child feeding, in households with a child under 2 years (n = 1827). Maternal exposure to Suaahara II had a positive association with minimum dietary diversity (OR: 1.71, 95% CI [1.27, 2.28], P < 0.001), minimum acceptable diet (OR: 1.60, 95% CI [1.19, 2.14], P = 0.002) and increased feeding to a sick child (OR: 2.11, 95% CI [1.41, 3.17], P < 0.001). Male household head exposure was only associated with increased feeding to a sick child (OR: 2.21, 95% CI [1.27, 3.84], P = 0.005). Among households with an exposed mother, having an exposed male household head nearly tripled the odds of appropriate sick child feeding (OR: 2.90, 95% CI [1.57, 5.34], P = 0.001) but was not significantly associated with the other two outcomes. These findings suggest that the relationships between exposure to nutrition programmes and outcomes are complex and further research is needed to understand variation by family member, behavioural outcome and context.

Parental depression and nutrition: findings from a cross-sectional household survey in Nepal.

OBJECTIVE: The present study aims to assess associations between parental depression and parental and child nutritional status and diets in Nepal. DESIGN: A cross-sectional survey conducted from June to September 2017. SETTING: This monitoring survey was conducted in sixteen of forty-two Suaahara intervention districts spanning mountains, hills and plains in Nepal. Multi-stage cluster sampling was used to sample communities in this survey. PARTICIPANTS: Women and men with a child 6-59 months of age were randomly selected (n 3158 mothers and children; n 826 fathers). RESULTS: Overall, 36 % of mothers, 37 % of fathers and 55 % of children met minimum dietary diversity, indicating that they consumed foods from at least four of seven food groups (children) and at least five of ten food groups (adults) in the 24 h prior to the interview. The percentage of children stunted, wasted and underweight was 28, 11 and 23, respectively. Only 5 % of mothers and 3 % of fathers screened positive for moderate or severe depression (Patient Health Questionnaire-9 score ≥ 10). In adjusted models, we found maternal depression was positively associated with maternal underweight (OR = 1·48, 95 % CI 1·01, 2·17). Maternal and paternal depression, however, were not associated with other indicators of anthropometric status or dietary diversity. CONCLUSIONS: Maternal and paternal depression, measured by the Patient Health Questionnaire-9, were not associated with dietary diversity or anthropometric status of fathers or children in Nepal, whereas depressed mothers were at increased risk of being underweight. Additional studies are needed to further assess relationships between mental health and nutritional outcomes.

Intimate partner violence and nutritional status among nepalese women: an investigation of associations.

BACKGROUND: Malnutrition among women in Nepal persists as a major public health burden. Global literature suggests that domestic violence may have a negative impact on women's nutritional status. The contribution of intimate partner violence (IPV) to increased stress levels, poor self-care including the consumption of less food and, in turn, malnutrition has been documented. However, there is little empirical evidence on IPV and its relationship with women's nutritional status in Nepal and thus, this paper assesses these associations. METHODS: We used data on non-pregnant married women (n = 3293) from the 2016 Nepal Demographic and Health Survey (NDHS). The primary exposure variable was whether the women had ever experienced physical, sexual, or emotional violence or controlling behaviours by a current or former partner, based on her responses to the NDHS domestic violence questions. The primary outcome variables were three indicators of malnutrition: under-weight (BMI < 18.5), over-weight (BMI > 25), and anemia (Hb < 11.0 g dL). We used logistic and multinomial regression models, adjusted for potential socio-demographic and economic confounders, as well as clustering, to examine associations between IPV exposure and malnutrition. RESULTS: Approximately 44% of women had experienced at least one of the four types of IPV. Among them, around 16, 25%. and 44% were underweight, overweight, or anemic, respectively, compared to 13, 29, and 35% of women never exposed to IPV. We did not find any associations between underweight and any of the four types of IPV. Overweight was associated with physical violence (adjusted RRR = 0.67, P < 0.01, CI = 0.50-0.88) and severe physical violence (adjusted RRR = 0.53, P < 0.05, CI = 0.32-0.88) Controlling behaviors were associated with anemia (adjusted RRR = 1.31, P < 0.01, CI = 1.11-1.54). CONCLUSIONS: Among married Nepalese women, physical violence appears to be a risk factor for one's weight and controlling behaviors for one's anemia status. Additional, rigorous, mixed-methods research is needed to understand the reporting of IPV and what relationships do or do not exist between IPV experience and nutrition both in Nepal and in other settings.

Maternal Decision-Making Input and Health-Seeking Behaviors Between Pregnancy and the Child's Second Birthday: A Cross-Sectional Study in Nepal.

OBJECTIVES: Maternal health-seeking behaviors are critical to improving maternal and child health in low-income countries. This study investigates associations between maternal decision-making input and their health-seeking behaviors in the first 1000-day period between pregnancy and a child's second birthday in Nepal. METHODS: We used data from a cross-sectional survey conducted in 2018 in 16 districts of Nepal. Among the 3648 households surveyed, 1910 mothers of a child 0 to 24 months with complete data were included for analyses. Logistic regression was used to examine associations between decision-making input and the utilization of antenatal, delivery and postnatal care services, and attendance at health mothers' group (HMG) meetings. We also used negative binomial regression to assess the relationship between her decision-making input and participation in growth monitoring and promotion (GMP) in the 6 months prior to the survey. For each relationship examined, we adjusted for clustering, as well as potentially confounding factors at individual and household levels. RESULTS: After adjusting for confounders, maternal decision-making input had a small but positive and significant association with receiving at least 4 antenatal care visits (OR = 1.09, 95% CI 1.02, 1.17), attendance at GMP in the 6 months prior to the survey (IRR = 1.02, 95% CI 1.00, 1.04), and HMG attendance (OR = 1.10, 95% CI 1.03, 1.17), but not with receiving at least 3 postnatal care visits or delivering in a health institution. CONCLUSIONS FOR PRACTICE: Our findings indicated that empowering women and mothers in household decision-making might warrant greater attention when developing future policies and programs in Nepal.

Exploring the Use of Mobile Health to Improve Community-Based Health and Nutrition Service Utilization in the Hills of Nepal: Qualitative Study.

BACKGROUND: With mobile phone coverage and ownership expanding globally, mobile health (mHealth) interventions are increasingly being used to improve coverage and quality of health and nutrition services. However, evidence on mHealth intervention feasibility and factors to consider during program design is limited in low- and middle-income countries like Nepal. OBJECTIVE: This study aimed to examine the potential of using text messages to improve health and nutrition services by exploring mobile phone ownership and sharing; mobile phone use and skills; and interest, preferences, and limitations regarding mHealth interventions. METHODS: We conducted 35 in-depth interviews with 1000-day women (the period from conception to a child's second birthday), health facility staff, and female community health volunteers (FCHVs), as well as eight focus group discussions with health facility staff, FCHVs, and 1000-day household decision-makers (ie, husbands, mothers-in-law, and fathers-in-law). We also conducted a mobile phone skills test. We employed thematic analysis using framework matrices and analytical memos. RESULTS: The study included 70 study participants, of whom 68 (97%) had a mobile phone, and phone sharing was uncommon. Use of text messages was most commonly reported by 1000-day women and health facility staff than household decision-makers and FCHVs. More than 8 in 10 participants (54/64, 84%) could dial numbers, and the majority (28/34, 82%) of 1000-day women, health facility staff, and male decision-makers could also read and write text messages. We found that 1000-day women preferred educational and reminder messages, whereas health facility staff and FCHVs desired educational and motivational messages. Participants suggested different types of texts for 1000-day women, families, FCHVs, and health facility staff, and reported less value for texts received from unknown phone numbers. CONCLUSIONS: A text message-based mHealth intervention is acceptable in the hills of Nepal and has the potential to improve community health and nutrition service utilization, particularly by sending meeting reminders and by providing information. Our findings contribute to text message-based mHealth intervention design in under-resourced settings.

COVID-19 and maternal and child food and nutrition insecurity: a complex syndemic.

Globally, the COVID-19 pandemic has already led to major increases in unemployment and is expected to lead to unprecedented increases in poverty and food and nutrition insecurity, as well as poor health outcomes. Families where young children, youth, pregnant and lactating women live need to be protected against the ongoing protracted pandemic and the aftershocks that are very likely to follow for years to come. The future wellbeing of the vast majority of the world now depends on reconfiguring the current ineffective food, nutrition, health, and social protection systems to ensure food and nutrition security for all. Because food, nutrition, health, and socio-economic outcomes are intimately inter-linked, it is essential that we find out how to effectively address the need to reconfigure and to provide better intersecoral coordination among global and local food, health care, and social protection systems taking equity and sutainability principles into account. Implementation science research informed by complex adaptive sytems frameworks will be needed to fill in the major knowledge gaps. Not doing so will not only put the development of individuals at further risk, but also negatively impact on the development potential of entire nations and ultimately our planet.

Women's bargaining power and child feeding in Nepal: Linkages through nutrition information.

Women's intra-household bargaining power is an important determinant of child nutritional status, but there is limited evidence on how it relates to infant and young child feeding (IYCF) practices. We conducted a cross-sectional analysis using 2012 baseline data from the impact evaluation of Suaahara, a multisectoral programme in Nepal, focusing on households with children 0-23 months (n = 1787). We examined if women's bargaining power was related to exposure to IYCF information and if exposure to IYCF information was in turn associated with improved IYCF practices: early initiation of breastfeeding, exclusive breastfeeding, minimum meal frequency and dietary diversity. Bargaining power consisted of four domains: (i) ownership and control of assets; (ii) social participation; (iii) workload; and (iv) household decision-making control and were primarily measured using additive scales. We used generalized structural equation modelling to examine if exposure to IYCF information mediated the relationship between the bargaining domains and the four IYCF practices, separately. Social participation was positively associated with exposure to IYCF information (ß = 0.266, P < .001), which in turn was related to early initiation (ß = 0.241, P = .001). We obtained similar results for the relationship between social participation and dietary diversity. Decision-making control was directly associated with exclusive breastfeeding (ß = 0.350, P = .036). No domains were associated with minimum meal frequency. Different domains of women's bargaining power may relate to exposure to nutrition information and IYCF behaviours. Understanding specific domains of bargaining power is critical to developing interventions that can effectively address gender-related issues that underlie child nutrition outcomes.

Barriers and facilitators to growth monitoring and promotion in Nepal: Household, health worker and female community health volunteer perceptions.

Growth monitoring and promotion (GMP) is both a service for diagnosing inadequate child growth in its earliest stages and a delivery platform for nutrition counselling. The widespread use of GMP services in developing countries has the potential to substantially reduce persistent child undernutrition through early diagnosis and by linking caregivers and their children to key health and nutrition services. However, researchers have questioned the effectiveness of GMP services, which are frequently undermined by underdeveloped health systems and inconsistent implementation. This analysis examined both supply- and demand-side factors for GMP utility in Nepal from the perspectives of beneficiaries and service providers, particularly focusing on three components of GMP: growth assessment, analysis of growth status and counselling. The most common factors influencing GMP uptake included beneficiaries' perceptions of the relative importance of GMP and the knowledge and skill of frontline workers. Both providers and beneficiaries viewed GMP as a secondary health and nutrition activity and therefore less important than curative services. We found deficits in GMP-related knowledge and skills among providers (i.e. health workers and female community health volunteers), as well as indications of poor training quality and coverage. Furthermore, we found variation in GMP utilization by maternal age, education and residency (alone, nuclear or extended), as well as household socio-economic well-being and rurality. This study is the first to assess factors influencing both beneficiaries and service providers for GMP utilization. Further research is needed to explore the implementation of improved GMP protocols and to evaluate facility-level implementation barriers.

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.

Water, sanitation, and hygiene practices mediate the association between women's empowerment and child length-for-age z-scores in Nepal.

In Nepal, more than one-third of children are stunted. Prior studies have shown that women's empowerment in agriculture is associated with child (<2 years) length-for-age z-scores (LAZ) in Nepal. This study tests whether child dietary diversity (DD) and household water, sanitation, and hygiene (WASH) facilities and practices mediate the associations between women's empowerment and LAZ. With a cross-sectional dataset of 4,080 households from 240 rural communities across 16 districts of Nepal, we used ordinary least squares regression models to first estimate the associations between women's empowerment and LAZ for children 6 to 24 months (n = 1,402; our previous published analysis included all children <24 months of age), using the Women's Empowerment in Agriculture Index's Five Domains of Empowerment subindex. We used standardized structural equation models to test whether child DD and/or household WASH mediated the association between women's empowerment and child LAZ. Overall, women's empowerment was positively associated with child LAZ (ß = 0.24, P = 0.03), as found in our previous analyses. In the mediation analysis, women's empowerment was positively associated with WASH (ß = 0.78, P < 0.001), and in turn child LAZ (ß = 0.09, P < 0.001). Women's empowerment was not associated with DD, but DD was associated with LAZ (ß = 0.06, P = 0.05). Empowered women had better WASH practices than nonempowered women, which translated into higher child LAZ. Child DD was not a mediating factor in the association between women's empowerment and child LAZ. More research is needed to explore other pathways by which women's empowerment may affect child nutrition outcomes.

Improving maternal, infant and young child nutrition in Nepal via peer mobilization.

OBJECTIVE: To evaluate the impact of a peer facilitator (PF) approach for improving mothers' knowledge and practices relating to maternal and child nutrition. DESIGN: A quasi-experimental design nested within a large-scale integrated nutrition programme, Suaahara, in Nepal. Suaahara interventions were implemented in all study sites, but peer facilitators were used in only half of the study sites. SETTING: Rural, disadvantaged villages in three districts of Nepal: Bhojpur, Bajhang and Rupandehi. SUBJECTS: Mothers of children aged 6-23·9 months (n 1890). RESULTS: Differences over time between comparison (C) and intervention (I) groups show that the PF approach had a significant positive impact on several indicators of mothers' knowledge and practices relating to maternal and child nutrition: (i) knowing that fruits and vegetables are good for children 6-23·9 months (C: -0·7, I: 10·6; P=0·03); (ii) child dietary diversity (C: 0·02, I: 0·04; P=0·02); (iii) child minimum dietary diversity (≥4 of 7 food groups; (C: 6·9, I: 16·0; P=0·02); (iv) maternal dietary diversity (C: 0·1, I: 0·4; P=0·01); and (v) maternal minimum dietary diversity (≥4 food groups; C: 3·6, I: 14·0; P=0·03). Additionally, exposure to a PF three or more times in the past 6 months was positively associated with a small improvement in maternal (ß=0·06, P=0·04) and child (ß=0·06, P=0·02) dietary diversity scores. Improvements were not observed in maternal health-seeking behaviours such as number of antenatal care visits. CONCLUSIONS: Peer mobilization is a potential approach for improving health- and nutrition-related knowledge and behaviours among women in hard-to-reach communities of Nepal.

Nutrition-sensitive agricultural interventions and gender dynamics: A qualitative study in Nepal.

Undernutrition and low women's status persist as major development obstacles in South Asia and specifically, Nepal. Multi-sectoral approaches, including nutrition-sensitive agriculture, are potential avenues for further reductions in undernutrition. Although evidence is growing, many questions remain regarding how gender mediates the translation of agricultural production activities into nutritional benefit. In this study, we examined how gender influences the pathway from agricultural production to improved income and control of income, with a focus on five domains of empowerment: decision-making power, freedom of mobility, social support, workload and time, and self-efficacy. For this, we conducted a qualitative retrospective assessment (N = 10 FGDs) among 73 beneficiary women of a nutrition-sensitive agriculture programme implemented from 2008 to 2012 in two districts of Nepal-Baitadi and Kailali. We found that women reported increased decision-making power, new knowledge and skills, increased recognition by their family members of their new knowledge and contributions, and self-efficacy as farmers and sellers, whereas workload and time were the most consistent constraints noted. We also found that each empowerment domain operated differently at different stages of the pathway, sometimes representing barriers and at other times, opportunities and that the interconnectedness of the domains made them difficult to disentangle in practice. Finally, there were major contextual differences for some domains (e.g., freedom of mobility) between the two districts. Future policies and programmes need to include in-depth formative research to ensure that interventions address context-specific gender and social norms to maximise programmatic opportunities to achieve desired results.

Grandmothers' knowledge positively influences maternal knowledge and infant and young child feeding practices.

OBJECTIVE: To examine associations between grandmothers' knowledge and infant and young child feeding (IYCF) practices and to test whether the associations are independent of or operate via maternal knowledge. DESIGN: Cross-sectional household survey data from households with a child under 5 years (n 4080). We used multivariate regression analyses, adjusted for child, maternal, grandmother and household characteristics, and district-level clustering, to test associations between grandmothers' knowledge and IYCF practices for children aged 6-24 months living with a grandmother. We used causal mediation to formally test the direct effect of grandmothers' knowledge on IYCF practices v. maternal knowledge mediating these associations. SETTING: Two hundred and forty rural communities, sixteen districts of Nepal. SUBJECTS: Children aged 6-24 months (n1399), including those living with grandmothers (n 748). RESULTS: We found that the odds of optimal breast-feeding practices were higher (early breast-feeding initiation: 2·2 times, P=0·002; colostrum feeding: 4·2 times, P<0·001) in households where grandmothers had correct knowledge v. those with incorrect knowledge. The same pattern was found for correct timing of introduction of water (2·6), milk (2·4), semi-solids (3·2), solids (2·9), eggs (2·6) and meat (2·5 times; all P<0·001). For the two pathways we were able to test, mothers' correct knowledge mediated these associations between grandmothers' knowledge and IYCF practices: colostrum feeding (b=10·91, P<0·001) and the introduction of complementary foods (b=5·18, P<0·001). CONCLUSIONS: Grandmothers' correct knowledge translated into mothers' correct knowledge and, therefore, optimal IYCF practices. Given grandmothers' influence in childcare, engagement of grandmothers in health and nutrition interventions could improve mothers' knowledge and facilitate better child feeding.