Consumption of Iron-Fortified Lentils Is Protective against Declining Iron Status among Adolescent Girls in Bangladesh: Evidence from a Community-Based Double-Blind, Cluster-Randomized Controlled Trial.

BACKGROUND: In many low-income countries, iron deficiency (ID) and its anemia (IDA) pose significant health challenges, particularly among females and girls. Finding sustainable and effective solutions to address this issue is critical. OBJECTIVES: This study aimed to evaluate the efficacy of incorporating iron-fortified lentils (IFLs) into the diets of rural Bangladeshi adolescent girls on their body iron (Fe) status. METHODS: A community-based, double-blind, cluster-randomized controlled trial involved n = 1195 girls aged 10-17 y. A total of 48 adolescent clubs (n = ∼27 girls each) were randomized into 3 groups: 1) 200 g cooked IFLs, 2) 200 g cooked noniron-fortified lentils (NIFLs), and 3) a control group with no lentils (usual dietary intake). The intervention, administered 5 days a week for 85 feeding days, provided ∼8.625 mg Fe from each serving of IFLs and 2.625 mg from NIFLs. Blood samples collected at baseline, midpoint (42 feeding days), and endpoint (85 feeding days) assessed key Fe and inflammation biomarkers. Statistical analyses were filtered for inflammation. RESULTS: Although all groups experienced a decline in Fe status over time, the IFL group exhibited a significantly reduced decline in serum ferritin (sFer -7.2 µg/L), and total body iron (TBI -0.48 mg/kg) level compared with NIFL (sFer -14.3 µg/L and TBI -1.36 mg/kg) and usual intake group (sFer -12.8 µg/L and TBI -1.33 mg/kg). Additionally, those in the IFL group had a 57% reduced risk of developing clinical ID (sFer <15 µg/L) compared with the usual intake group. CONCLUSIONS: Our findings suggest that incorporating IFLs into the diet can help mitigate a decline in sFer, indicating a positive impact on the body Fe status of adolescent girls. This research underscores the potential role of fortified foods in addressing ID and IDA in vulnerable populations, emphasizing the significance of food-based interventions in public health. TRIAL REGISTRATION NUMBER: This trial was registered at the clinicaltrials.gov on May 24, 2018 (https://clinicaltrials.gov/study/NCT03516734?locStr=Bangladesh&country=Bangladesh&distance=50&cond=Anemia&intr=Iron%20fortified%20lentils&rank=1) as NCT03516734.

Acceptability of a balanced energy protein (BEP) supplement for pregnant women in Bangladesh.

Balanced energy protein (BEP) supplementation in pregnancy is recommended in the context of undernutrition for the reduction of small-for-gestational age neonates and stillbirths. To inform an effectiveness trial, we evaluated the acceptability of a packaged, ready-to-eat fortified BEP product among women of reproductive age and their health care providers (HCPs) in rural Bangladesh and explored the feasibility of adhering to daily supplementation. We implemented a formative study using focus groups discussions with women (n = 29) and HCPs (n = 17) to introduce the product and investigate components of acceptability. A "trials of improved practice" activity was conducted in subset of women (n = 16) to evaluate adherence to BEP over a 2-week period, followed by focus group discussions to identify challenges with adherence and strategies employed. Contributors to BEP acceptability included the product's sensory attributes, such as taste, smell and texture; the attractive packaging and informative labelling; and the perceived benefits of use. Participants also identified household and community level factors influencing the adoption of BEP, such as trust in the provider, cultural beliefs on supplement use in pregnancy, and family member tasting and approval. Over the 2-week period, women consumed over 80% of the supplements provided to them and identified strategies for adherence, including visual aids and reminders from family members or providers. HCPs recommended targeted communication messages for mothers-in-law to foster a supportive home environment. Findings informed changes to the BEP product to improve acceptability and shaped the content of communication messages to optimise adherence in a forthcoming effectiveness trial.

Assessing implementation outcomes for launching balanced energy protein supplementation: A formative study in rural Bangladesh.

Balanced energy protein (BEP) supplementation is an efficacious intervention in pregnancy for improving birthweight and is recommended by World Health Organization (WHO) in countries with high maternal undernutrition. Few countries have implemented BEP programmes due in part to high cost, lack of data on acceptability and feasibility, and complexity of delivery. We sought to address implementation gaps in BEP interventions through a formative study designed to understand implementation outcomes. We conducted 52 in-depth interviews and 8 focus-group discussions with married women of reproductive age, family members, health care providers and pharmacists in three unions of the Gaibandha district in rural Bangladesh. Interviews were translated and transcribed in English and analysed using an analytic framework for implementation science in nutrition. BEP was viewed as an acceptable and appropriate intervention to combat undernutrition in this setting. There was a lack of clarity on who should or could be responsible for providing/distributing BEP in a way convenient to mothers. Many participants preferred door-to-door delivery and thought this approach could address social and gender inequities, but providers mentioned already being overworked and worried about adding new tasks. Participants were concerned about the affordability of BEP and opportunity costs associated with travel to proposed distribution sites such as ANC or pharmacies. Women in these communities do not always have the agency to travel without supervision or make purchasing decisions. BEP supplementation is a complex intervention; future trials seek to assess ways to overcome these implementation challenges and inform a long-term systems-owned BEP intervention.

Exploring theory-based behavioral interventions promoting COVID-19 prevention and healthcare-seeking for migrant worker men in Singapore: a qualitative study.

BACKGROUND: The first wave of COVID-19 during April to July 2020 in Singapore largely affected the migrant workers living in residential dormitories. A government taskforce working with dormitory operators, employers and non-government agencies came together to deliver behavioral interventions and health care services for migrant worker as dorms were imposed movement restrictions. To fill the research gap in understanding movement restriction experiences of migrant workers, this research seeks to describe dormitory contexts and explore behavior change related to both prevention of transmission as well as healthcare seeking for COVID-19 among male migrant workers. METHODS: With social constructivism as the foundation for this study, 23 telephone interviews were conducted with Bangladeshi and Indian migrant workers. A theory-informed, data-driven conceptual framework, characterized by the "Four Ss": Sensitization, Surveillance, Self-preservation, and Segregation was first generated and later used to frame second-stage, more in-depth, thematic analyses. An effective multipronged approach was documented, persuading migrant workers in our case-study to improve hygiene and follow some safe distancing measures, and adhere to help-seeking when symptomatic. RESULTS: Rapid collective adaptation was demonstrated; it was propped up by effective harnessing of infrastructure and technology. While technology and digital platforms were central to shaping Sensitization for prevention-related behaviors, interpersonal communication, especially peer-sharing, was key to normalizing and accepting healthcare delivery and norms about healthcare seeking. Interpersonal factors particularly supported successful implementation of case-detection Surveillance, stimulating Self-preserving and acceptance of rules, and was found helpful to those Segregated in recovery facilities. In contrast, encouraging prevention-related behaviors relied more heavily on multiple online-platforms, phone-based e-learning/knowledge testing, e-monitoring of behavior, as well as interpersonal exchanges. CONCLUSION: Overall, the findings showed that the conception of the Four Ss helped inform intervention strategies. Anchoring these towards optimal use of technology and harnessing of interpersonal communication for prevention and promotion of healthcare seeking in the planning of future Infectious Disease outbreaks in closed institutional settings is recommended.

Social Innovation For Health Research: Development of the SIFHR Checklist.

BACKGROUND: Social innovations in health are inclusive solutions to address the healthcare delivery gap that meet the needs of end users through a multi-stakeholder, community-engaged process. While social innovations for health have shown promise in closing the healthcare delivery gap, more research is needed to evaluate, scale up, and sustain social innovation. Research checklists can standardize and improve reporting of research findings, promote transparency, and increase replicability of study results and findings. METHODS AND FINDINGS: The research checklist was developed through a 3-step community-engaged process, including a global open call for ideas, a scoping review, and a 3-round modified Delphi process. The call for entries solicited checklists and related items and was open between November 27, 2019 and February 1, 2020. In addition to the open call submissions and scoping review findings, a 17-item Social Innovation For Health Research (SIFHR) Checklist was developed based on the Template for Intervention Description and Replication (TIDieR) Checklist. The checklist was then refined during 3 rounds of Delphi surveys conducted between May and June 2020. The resulting checklist will facilitate more complete and transparent reporting, increase end-user engagement, and help assess social innovation projects. A limitation of the open call was requiring internet access, which likely discouraged participation of some subgroups. CONCLUSIONS: The SIFHR Checklist will strengthen the reporting of social innovation for health research studies. More research is needed on social innovation for health.

Maternal nutrition intervention and maternal complications in 4 districts of Bangladesh: A nested cross-sectional study.

BACKGROUND: Maternal morbidity is common in Bangladesh, where the maternal mortality rate has plateaued over the last 6 years. Maternal undernutrition and micronutrient deficiencies contribute to morbidity, but few interventions have measured maternal outcomes. We compared reported prevalence of antepartum, intrapartum, and postpartum complications among recently delivered women between maternal nutrition intervention and control areas in Bangladesh. METHODS AND FINDINGS: We conducted a cross-sectional assessment nested within a population-based cluster-randomized trial comparing a nutrition counseling and micronutrient supplement intervention integrated within a structured home-based maternal, newborn, and child health (MNCH) program to the MNCH program alone in 10 sub-districts each across 4 Bangladesh districts. Eligible consenting women, delivering within 42-60 days of enrollment and identified by community-level health workers, completed an interviewer-administered questionnaire detailing the index pregnancy and delivery and allowed review of their home-based care register. We compared pooled and specific reported antepartum, intrapartum, and postpartum complications between study groups using hierarchical logistic regression. There were 594 women in the intervention group and 506 in the control group; overall, mean age was 24 years, 31% were primiparas, and 39% reported facility-based delivery, with no significant difference by study group. There were no significant differences between the intervention and control groups in household-level characteristics, including reported mean monthly income (intervention, 6,552 taka, versus control, 6,017 taka; p = 0.48), having electricity (69.6% versus 71.4%, p = 0.84), and television ownership (41.1% versus 38.7%, p = 0.81). Women in the intervention group had higher recorded iron and folic acid and calcium supplement consumption and mean dietary diversity scores, but reported anemia rates were similar between the 2 groups (5.7%, intervention; 6.5%, control; p = 0.83). Reported antepartum (69.4%, intervention; 79.2%, control; p = 0.12) and intrapartum (41.4%, intervention; 48.5%, control; p = 0.18) complication rates were high and not significantly different between groups. Reported postpartum complications were significantly lower among women in the intervention group than the control group (33.5% versus 48.2%, p = 0.02), and this difference persisted in adjusted analysis (adjusted odds ratio [AOR] = 0.51, 95% CI 0.32-0.82; p < 0.001). For specific conditions, odds of retained placenta (AOR = 0.35, 95% CI 0.19-0.67; p = 0.001), postpartum bleeding (AOR = 0.37, 95% CI 0.15-0.92; p = 0.033), and postpartum fever/infection (AOR = 0.27, 95% CI 0.11-0.65; p = 0.001) were significantly lower in the intervention group in adjusted analysis. There were no significant differences in reported hospitalization for antepartum (49.8% versus 45.1%, p = 0.37), intrapartum (69.9% versus 59.8%, p = 0.18), or postpartum (36.1% versus 29.9%, p = 0.49) complications between the intervention and control groups. The main limitations of this study are outcome measures based on participant report, non-probabilistic selection of community-level workers' catchment areas for sampling, some missing data for variables derived from secondary sources (e.g., dietary diversity score), and possible recall bias for reported dietary intake and supplement use. CONCLUSIONS: Reported overall postpartum and specific intrapartum and postpartum complications were significantly lower for women in intervention areas than control areas, despite similar rates of facility-based delivery and hospitalization for reported complications, in this exploratory analysis. Maternal nutrition interventions providing intensive counseling and micronutrient supplements may reduce some pregnancy complications or impact women's ability to accurately recognize complications, but more rigorous evaluation is needed for these outcomes.

Individual-, maternal- and household-level factors associated with stunting among children aged 0-23 months in Bangladesh.

OBJECTIVE: Childhood stunting remains a major public health concern in Bangladesh. To accelerate the reduction rate of stunting, special focus is required during the first 23 months of a child's life when the bulk of growth takes place. Therefore the present study explored individual-, maternal- and household-level factors associated with stunting among children under 2 years of age in Bangladesh. DESIGN: Data were collected through a nationwide cross-sectional survey conducted between October 2015 and January 2016. A two-stage cluster random sampling procedure was applied to select 11 428 households. In the first stage, 210 enumerations areas (EA) were selected with probability proportional to EA size (180 EA from rural areas, thirty EA from urban slums). In the second stage, an average of fifty-four households were selected from each EA through systematic random sampling. SETTING: Rural areas and urban slums of Bangladesh.ParticipantsA total of 6539 children aged 0-23 months. RESULTS: Overall, 29·9 % of the children were stunted. After adjusting for all potential confounders in the modified Poisson regression model, child's gender, birth weight (individual level), maternal education, age at first pregnancy, nutrition (maternal level), administrative division, place of residence, socio-economic status, food security status, access to sanitary latrine and toilet hygiene condition (household level) were significantly associated with stunting. CONCLUSIONS: The study identified a number of potentially addressable multilevel risk factors for stunting among young children in Bangladesh that should be addressed through comprehensive multicomponent interventions.

Study protocol to assess the impact of an integrated nutrition intervention on the growth and development of children under two in rural Bangladesh.

BACKGROUND: The period from birth to two years is the "critical window" for achieving optimal growth and development. An inadequate quality and quantities of complementary foods, poor child-feeding practices and infection negatively impact the growth of under-twos. Approximately one-third of under-fives in developing countries are stunted; many are also micronutrient deficient. An estimated 6% of mortalities among under-fives can be prevented by ensuring optimal complementary feeding. The objective of the study was to assess the ability of a 12-month integrated nutrition intervention to improve the nutritional status (length-for-age Z-score) of 6 to 12-month-old children in rural Bangladesh. METHODS: In this community-based randomized controlled trial, the intervention group received a package of interventions that includes, food vouchers; to prepare egg-based nutritious snacks (suji firni for < 1-year-olds, suji halwa for > 1-year-olds), micronutrient powder to fortify children's food at home, child feeding counselling and water, sanitation and hygiene (WASH), behaviour change communication. The control group received routine health messages provided by the government. Baseline and endline surveys were conducted; Data collection was performed monthly on children's growth, food voucher utilization, child feeding and morbidity. In addition, we assessed the cognitive development of the children after 12 months of intervention. CONCLUSION: This trial aims to explore whether an integrated nutrition intervention can mitigate childhood stunting during the critical window of opportunity in rural Bangladesh. The results may provide robust evidence to improve the linear growth of children in developing countries. TRIAL REGISTRATION: The study was retrospectively registered on August 17, 2018 and is available online at ClinicalTrials.gov (ID: NCT02768181).

Large-Scale Social and Behavior Change Communication Interventions Have Sustained Impacts on Infant and Young Child Feeding Knowledge and Practices: Results of a 2-Year Follow-Up Study in Bangladesh.

Background: Sustained improvements in infant and young child feeding (IYCF) require continued implementation of effective interventions. From 2010-2014, Alive & Thrive (A&T) provided intensive interpersonal counseling (IPC), community mobilization (CM), and mass media (MM) in Bangladesh, demonstrating impact on IYCF practices. Since 2014, implementation has been continued and scaled up by national partners with support from other donors and with modifications such as added focus on maternal nutrition and reduced program intensity. Objective: We assessed changes in intervention exposure and IYCF knowledge and practices in the intensive (IPC + CM + MM) compared with nonintensive areas (standard nutrition counseling + less intensive CM and MM) 2 y after termination of initial external donor support. Methods: We used a cluster-randomized design with repeated cross-sectional surveys at baseline (2010, n = 2188), endline (2014, n = 2001), and follow-up (2016, n = 2400) in the same communities, among households with children 0-23.9 mo of age. Within-group differences over time and differences between groups in changes were tested. Results: In intensive areas, exposure to IPC decreased slightly between endline and follow-up (88.9% to 77.2%); exposure to CM activities decreased significantly (29.3% to 3.6%); and MM exposure was mostly unchanged (28.1-69.1% across 7 TV spots). Exposure to interventions did not expand in nonintensive areas. Most IYCF indicators in intensive areas declined from endline to follow-up, but remained higher than at baseline. Large differential improvements of 12-17 percentage points in intensive, compared with nonintensive areas, between baseline and follow-up remained for early initiation of and exclusive breastfeeding, timely introduction of foods, and consumption of iron-rich foods. Differential impact in breastfeeding knowledge remained between baseline and follow-up; complementary feeding knowledge increased similarly in both groups. Conclusions: Continued IPC exposure and sustained impacts on IYCF knowledge and practices in intensive areas indicated lasting benefits from A&T's interventions as they underwent major scale-up with reduced intensity. This trial was registered at clinicaltrials.gov as NCT02740842.

Engagement of Husbands in a Maternal Nutrition Program Substantially Contributed to Greater Intake of Micronutrient Supplements and Dietary Diversity during Pregnancy: Results of a Cluster-Randomized Program Evaluation in Bangladesh.

Background: Although husbands may provide support during pregnancy, limited evidence exists on how to promote husbands' engagement and what impact it has. Alive & Thrive integrated nutrition-focused interventions, targeting both wives and husbands, through an existing Maternal, Neonatal, and Child Health (MNCH) platform in Bangladesh. Objectives: We evaluated 1) the impact of a nutrition-focused MNCH program, compared with the standard MNCH program, on husbands' behavioral determinants (i.e., awareness, knowledge, self-efficacy) and support to wives to adopt optimal nutrition practices and 2) how much of the previously documented impact on women's supplement intake and dietary diversity was explained by husbands' behavioral determinants and support. Methods: We used a cluster-randomized design with cross-sectional surveys at baseline (2015) and endline (2016) (n = ∼1000 women and ∼700 husbands/survey). We used mixed linear regression accounting for clustering to estimate difference-in-differences (DIDs) for impact on husbands' behavioral determinants and path analysis to examine how much these determinants explained the impact on women's nutrition behaviors. Results: Of husbands in the nutrition-focused MNCH group, 62% were counseled by health workers, 66% attended a husbands' forum, and 34% saw video shows. The nutrition-focused MNCH, compared with the standard MNCH group, resulted in greater husbands' awareness (DID: 2.74 of 10 points), knowledge (DID: 1.31), self-efficacy and social norms with regard to optimal nutrition practices (difference: 1.08), and support to their wives (DID: 1.86). Husbands' behavioral determinants and support explained nearly half of the program impact for maternal supplement intake and one-quarter for dietary diversity. Conclusions: A nutrition-focused MNCH program that promoted and facilitated husbands' engagement during their wives' pregnancies significantly improved husbands' awareness, knowledge, self-efficacy, and support. These improvements substantially explained the program's impact on women's intake of micronutrient supplements and dietary diversity. Targeting wives and husbands and designing activities to engage men in maternal nutrition programs are important to maximize impact. This trial was registered at www.clinicaltrials.gov as NCT02745249.

The association between daily 500 mg calcium supplementation and lower pregnancy-induced hypertension risk in Bangladesh.

BACKGROUND: Evidence suggests that daily supplementation of 1500 to 2000 mg of calcium during pregnancy reduces pregnancy-induced hypertension (PIH). However, the evidence on the efficacy of low-dose calcium supplementation on PIH is limited. This paper assesses the longitudinal correlation between low-dose calcium intake (500 mg daily) and change in blood pressure during pregnancy among a homogeneous population in terms of hypertension and pre-eclampsia. METHODS: The study followed a retrospective cohort study design, and was carried out among 11,387 pregnant women from 10 rural upazilas (sub-districts) of Bangladesh where maternal nutrition initiative (MNI), implemented by Building Resources Across Communities (BRAC), was ongoing. The modified Poisson regression model was used to estimate the association (risk ratio) between consumption of calcium tablets and PIH. RESULTS: The present research found that women who consumed 500 mg/d calcium tablets for more than 6 months during their pregnancy had a 45% lower risk of developing hypertension compared to those who consumed less calcium (RR = 0.55, 95% CI = 0.33-0.93). CONCLUSIONS: Daily supplementation of 500 mg oral calcium during pregnancy for at least 180 tablets is associated with a considerably reduced risk of PIH, but this study is unable to confirm whether this association is causal. The causal relationship needs to be confirmed through a large scale randomized controlled trial.

A community-based cluster randomised controlled trial in rural Bangladesh to evaluate the impact of the use of iron-folic acid supplements early in pregnancy on the risk of neonatal mortality: the Shonjibon trial.

BACKGROUND: Iron-deficiency is the most common nutritional deficiency globally. Due to the high iron requirements for pregnancy, it is highly prevalent and severe in pregnant women. There is strong evidence that maternal iron deficiency anaemia increases the risk of adverse perinatal outcomes. However, most of the evidence is from observational epidemiological studies except for a very few randomised controlled trials. IFA supplements have also been found to reduce the preterm delivery rate and neonatal mortality attributable to prematurity and birth asphyxia. These results combined indicate that IFA supplements in populations of iron-deficient pregnant women could lead to a decrease in the number of neonatal deaths mediated by reduced rates of preterm delivery. In this paper, we describe the protocol of a community-based cluster randomised controlled trial that aims to evaluate the impact of maternal antenatal IFA supplements on perinatal outcomes. METHODS/DESIGN: The effect of the early use of iron-folic acid supplements on neonatal mortality will be examined using a community based, cluster randomised controlled trial in five districts with 30,000 live births. In intervention clusters trained BRAC village volunteers will identify pregnant women & provide iron-folic acid supplements. Groundwater iron levels will be measured in all study households using a validated test kit. The analysis will follow the intention to treat principle. We will compare neonatal mortality rates & their 95% confidence intervals adjusted for clustering between treatment groups in each groundwater iron-level group. Cox proportional hazards mixed models will be used for mortality outcomes & will include groundwater iron level as an interaction term in the mortality model. DISCUSSION: This paper aims to describe the study protocol of a community based randomised controlled trial evaluating the impact of the use of iron-folic acid supplements early in pregnancy on the risk of neonatal mortality. This study is critical because it will determine if antenatal IFA supplements commenced in the first trimester of pregnancy, rather than later, will significantly reduce neonatal deaths in the first month of life, and if this approach is cost-effective. TRIAL REGISTRATION: This trial has been registered with the Australian New Zealand Clinical Trials Registry (ANZCTR) on 31 May 2012. The registration ID is ACTRN12612000588897 .

Next generation maternal health: external shocks and health-system innovations.

In this Series we document the substantial progress in the reduction of maternal mortality and discuss the current state of science in reducing maternal mortality. However, maternal health is also powerfully influenced by the structures and resources of societies, communities, and health systems. We discuss the shocks from outside of the field of maternal health that will influence maternal survival including economic growth in low-income and middle-income countries, urbanisation, and health crises due to disease outbreaks, extreme weather, and conflict. Policy and technological innovations, such as universal health coverage, behavioural economics, mobile health, and the data revolution, are changing health systems and ushering in new approaches to affect the health of mothers. Research and policy will need to reflect the changing maternal health landscape.

Large-Scale Behavior-Change Initiative for Infant and Young Child Feeding Advanced Language and Motor Development in a Cluster-Randomized Program Evaluation in Bangladesh.

BACKGROUND: Promoting adequate nutrition through interventions to improve infant and young child feeding (IYCF) has the potential to contribute to child development. OBJECTIVE: We examined whether an intensive intervention package that was aimed at improving IYCF at scale through the Alive & Thrive initiative in Bangladesh also advanced language and gross motor development, and whether advancements in language and gross motor development were explained through improved complementary feeding. METHODS: A cluster-randomized design compared 2 intervention packages: intensive interpersonal counseling on IYCF, mass media campaign, and community mobilization (intensive) compared with usual nutrition counseling and mass media campaign (nonintensive). Twenty subdistricts were randomly assigned to receive either the intensive or the nonintensive intervention. Household surveys were conducted at baseline (2010) and at endline (2014) in the same communities (n = ∼4000 children aged 0-47.9 mo for each round). Child development was measured by asking mothers if their child had reached each of multiple milestones, with some observed. Linear regression accounting for clustering was used to derive difference-in-differences (DID) impact estimates, and path analysis was used to examine developmental advancement through indicators of improved IYCF and other factors. RESULTS: The DID in language development between intensive and nonintensive groups was 1.05 milestones (P = 0.001) among children aged 6-23.9 mo and 0.76 milestones (P = 0.038) among children aged 24-47.9 mo. For gross motor development, the DID was 0.85 milestones (P = 0.035) among children aged 6-23.9 mo. The differences observed corresponded to age- and sex-adjusted effect sizes of 0.35 for language and 0.23 for gross motor development. Developmental advancement at 6-23.9 mo was partially explained through improved minimum dietary diversity and the consumption of iron-rich food. CONCLUSIONS: Intensive IYCF intervention differentially advanced language and gross motor development, which was partially explained through improved complementary feeding. Measuring a diverse set of child outcomes, including functional outcomes such as child development, is important when evaluating integrated nutrition programs. This trial was registered at clinicaltrials.gov as NCT01678716.

Integrating Nutrition Interventions into an Existing Maternal, Neonatal, and Child Health Program Increased Maternal Dietary Diversity, Micronutrient Intake, and Exclusive Breastfeeding Practices in Bangladesh: Results of a Cluster-Randomized Program Evaluation.

Background: Maternal undernutrition is a major concern globally, contributing to poor birth outcomes. Limited evidence exists on delivering multiple interventions for maternal nutrition simultaneously. Alive & Thrive addressed this gap by integrating nutrition-focused interpersonal counseling, community mobilization, distribution of free micronutrient supplements, and weight-gain monitoring through an existing Maternal, Neonatal, and Child Health (MNCH) program in Bangladesh.Objectives: We evaluated the effect of providing nutrition-focused MNCH compared with standard MNCH (antenatal care with standard nutrition counseling) on coverage of nutrition interventions, maternal dietary diversity, micronutrient supplement intake, and early breastfeeding practices.Methods: We used a cluster-randomized design with cross-sectional surveys at baseline (2015) and endline (2016) (n ∼ 300 and 1000 pregnant or recently delivered women, respectively, per survey round). We derived difference-in-difference effect estimates, adjusted for geographic clustering and infant age and sex.Results: Coverage of interpersonal counseling was high; >90% of women in the nutrition-focused MNCH group were visited at home by health workers for maternal nutrition and breastfeeding counseling. The coverage of community mobilization activities was ∼50%. Improvements were significantly greater in the nutrition-focused MNCH group than in the standard MNCH group for consumption of iron and folic acid [effect: 9.8 percentage points (pp); 46 tablets] and calcium supplements (effect: 12.8 pp; 50 tablets). Significant impacts were observed for the number of food groups consumed (effect: 1.6 food groups), percentage of women who consumed ≥5 food groups/d (effect: 30.0 pp), and daily intakes of several micronutrients. A significant impact was also observed for exclusive breastfeeding (EBF; effect: 31 pp) but not for early initiation of breastfeeding.Conclusions: Addressing nutrition during pregnancy by delivering interpersonal counseling and community mobilization, providing free supplements, and ensuring weight-gain monitoring through an existing MNCH program improved maternal dietary diversity, micronutrient supplement consumption, and EBF practices. This trial was registered at clinicaltrials.gov as NCT02745249.

Impacts on Breastfeeding Practices of At-Scale Strategies That Combine Intensive Interpersonal Counseling, Mass Media, and Community Mobilization: Results of Cluster-Randomized Program Evaluations in Bangladesh and Viet Nam.

BACKGROUND: Despite recommendations supporting optimal breastfeeding, the number of women practicing exclusive breastfeeding (EBF) remains low, and few interventions have demonstrated implementation and impact at scale. Alive & Thrive was implemented over a period of 6 y (2009-2014) and aimed to improve breastfeeding practices through intensified interpersonal counseling (IPC), mass media (MM), and community mobilization (CM) intervention components delivered at scale in the context of policy advocacy (PA) in Bangladesh and Viet Nam. In Bangladesh, IPC was delivered through a large non-governmental health program; in Viet Nam, it was integrated into government health facilities. This study evaluated the population-level impact of intensified IPC, MM, CM, and PA (intensive) compared to standard nutrition counseling and less intensive MM, CM, and PA (non-intensive) on breastfeeding practices in these two countries. METHODS AND FINDINGS: A cluster-randomized evaluation design was employed in each country. For the evaluation sample, 20 sub-districts in Bangladesh and 40 communes in Viet Nam were randomized to either the intensive or the non-intensive group. Cross-sectional surveys (n ~ 500 children 0-5.9 mo old per group per country) were implemented at baseline (June 7-August 29, 2010, in Viet Nam; April 28-June 26, 2010, in Bangladesh) and endline (June 16-August 30, 2014, in Viet Nam; April 20-June 23, 2014, in Bangladesh). Difference-in-differences estimates (DDEs) of impact were calculated, adjusting for clustering. In Bangladesh, improvements were significantly greater in the intensive compared to the non-intensive group for the proportion of women who reported practicing EBF in the previous 24 h (DDE 36.2 percentage points [pp], 95% CI 21.0-51.5, p < 0.001; prevalence in intensive group rose from 48.5% to 87.6%) and engaging in early initiation of breastfeeding (EIBF) (16.7 pp, 95% CI 2.8-30.6, p = 0.021; 63.7% to 94.2%). In Viet Nam, EBF increases were greater in the intensive group (27.9 pp, 95% CI 17.7-38.1, p < 0.001; 18.9% to 57.8%); EIBF declined (60.0% to 53.2%) in the intensive group, but less than in the non-intensive group (57.4% to 40.6%; DDE 10.0 pp, 95% CI -1.3 to 21.4, p = 0.072). Our impact estimates may underestimate the full potential of such a multipronged intervention because the evaluation lacked a "pure control" area with no MM or national/provincial PA. CONCLUSIONS: At-scale interventions combining intensive IPC with MM, CM, and PA had greater positive impacts on breastfeeding practices in Bangladesh and Viet Nam than standard counseling with less intensive MM, CM, and PA. To our knowledge, this study is the first to document implementation and impacts of breastfeeding promotion at scale using rigorous evaluation designs. Strategies to design and deliver similar programs could improve breastfeeding practices in other contexts. TRIAL REGISTRATION: ClinicalTrials.gov NCT01678716 (Bangladesh) and NCT01676623 (Viet Nam).

Combining Intensive Counseling by Frontline Workers with a Nationwide Mass Media Campaign Has Large Differential Impacts on Complementary Feeding Practices but Not on Child Growth: Results of a Cluster-Randomized Program Evaluation in Bangladesh.

BACKGROUND: Complementary feeding (CF) contributes to child growth and development, but few CF programs are delivered at scale. Alive & Thrive addressed this in Bangladesh through intensified interpersonal counseling (IPC), mass media (MM), and community mobilization (CM). OBJECTIVE: The objective was to evaluate the impact of providing IPC + MM + CM (intensive) compared with standard nutrition counseling + less intensive MM + CM (nonintensive) on CF practices and anthropometric measurements. METHODS: We used a cluster-randomized, nonblinded evaluation with cross-sectional surveys [n = ∼600 and 1090 children 6-23.9 mo and 24-47.9 mo/group, respectively, at baseline (2010) and n = ∼500 and 1100 children of the same age, respectively, at endline (2014)]. We derived difference-in-difference impact estimates (DDEs), adjusting for geographic clustering, infant age, sex, differences in baseline characteristics, and differential change in characteristics over time. RESULTS: Groups were similar at baseline. CF improvements were significantly greater in the intensive than in the nonintensive group [DDEs: 16.3, 14.7, 22.0, and 24.6 percentage points (pp) for minimum dietary diversity, minimum meal frequency, minimum acceptable diet, and consumption of iron-rich foods, respectively]. In the intensive group, CF practices were high: 50.4% for minimum acceptable diet, 63.8% for minimum diet diversity, 75.1% for minimum meal frequency, and 78.5% for consumption of iron-rich foods. Timely introduction of foods improved. Significant, nondifferential stunting declines occurred in intensive (6.2 pp) and nonintensive (5.2 pp) groups in children 24-47.9 mo. CONCLUSIONS: The intensive program substantially improved CF practices compared with the nonintensive program. Large-scale program delivery was feasible and, with the use of multiple platforms, reached 1.7 million households. Nondifferential impacts on stunting were likely due to rapid positive secular trends in Bangladesh. Accelerating linear growth further could require accompanying interventions. This study establishes proof of concept for large-scale behavior change interventions to improve child feeding. This trial was registered at clinicaltrials.gov as NCT01678716.

First Steps in Initiating an Effective Maternal, Neonatal, and Child Health Program in Urban Slums: the BRAC Manoshi Project's Experience with Community Engagement, Social Mapping, and Census Taking in Bangladesh.

The processes for implementing effective programs at scale in low-income countries have not been well-documented in the peer-reviewed literature. This article describes the initial steps taken by one such program--the BRAC Manoshi Project, which now reaches a population of 6.9 million. The project has achieved notable increases in facility births and reductions in maternal and neonatal mortality. The focus of the paper is on the initial steps--community engagement, social mapping, and census taking. Community engagement began with (1) engaging local leaders, (2) creating Maternal, Neonatal, and Child Health Committees for populations of approximately 10,000 people, (3) responding to advice from the community, (4) social mapping of the community, and (5) census taking. Social mapping involved community members working with BRAC staff to map all important physical features that affect how the community carries out its daily functions--such as alleys, lanes and roads, schools, mosques, markets, pharmacies, health facilities, latrine sites, and ponds. As the social mapping progressed, it became possible to conduct household censuses with maps identifying every household and listing family members by household. Again, this was a process of collaboration between BRAC staff and community members. Thus, social mapping and census taking were also instrumental for advancing community engagement. These three processes-community engagement, social mapping, and census taking--can be valuable strategies for strengthening health programs in urban slum settings of low-income countries.

Achieving behaviour change at scale: Alive & Thrive's infant and young child feeding programme in Bangladesh.

The Alive & Thrive programme scaled up infant and young child feeding interventions in Bangladesh from 2010 to 2014. In all, 8.5 million mothers benefited. Approaches - including improved counselling by frontline health workers during home visits; community mobilization; mass media campaigns reaching mothers, fathers and opinion leaders; and policy advocacy - led to rapid and significant improvements in key practices related to breastfeeding and complementary feeding. (Evaluation results are forthcoming.) Intervention design was based on extensive formative research and behaviour change theory and principles and was tailored to the local context. The programme focused on small, achievable actions for key audience segments identified through rigorous testing. Promotion strategies took into account underlying behavioural determinants and reached a high per cent of the priority groups through repeated contacts. Community volunteers received monetary incentives for mothers in their areas who practised recommended behaviours. Programme monitoring, midterm surveys and additional small studies to answer questions led to ongoing adjustments. Scale-up was achieved through streamlining of tools and strategies, government branding, phased expansion through BRAC - a local non-governmental implementing partner with an extensive community-based platform - and nationwide mainstreaming through multiple non-governmental organization and government programmes. Key messages Well-designed and well-implemented large-scale interventions that combine interpersonal counselling, community mobilization, advocacy, mass communication and strategic use of data have great potential to improve IYCF practices rapidly. Formative research and ongoing studies are essential to tailor strategies to the local context and to the perspectives of mothers, family members, influential community members and policymakers. Continued use of data to adjust programme elements is also central to the process. Scale-up can be facilitated through strategic selection of partners with existing community-based platforms and through mass media, where a high proportion of the target audience can be reached through communication channels such as broadcast media. Sustaining the impacts will involve commitments from government and capacity building. The next step for capacity building would involve understanding barriers and constraints and then coming up with appropriate strategies to address them. One of the limitations we experienced was rapid transition of staff in key positions of implementing agencies, in government leadership, donors and other stakeholders. There was a need for continued advocacy, orientation and teaching related to strategic programme design, behaviour change, effective implementation and use of data.