Evaluation of an unconditional cash transfer program targeting children's first-1,000-days linear growth in rural Togo: A cluster-randomized controlled trial.

BACKGROUND: In 2014, the government of Togo implemented a pilot unconditional cash transfer (UCT) program in rural villages that aimed at improving children's nutrition, health, and protection. It combined monthly UCTs (approximately US$8.40 /month) with a package of community activities (including behavior change communication [BCC] sessions, home visits, and integrated community case management of childhood illnesses and acute malnutrition [ICCM-Nut]) delivered to mother-child pairs during the first "1,000 days" of life. We primarily investigated program impact at population level on children's height-for-age z-scores (HAZs) and secondarily on stunting (HAZ < -2) and intermediary outcomes including household's food insecurity, mother-child pairs' diet and health, delivery in a health facility and low birth weight (LBW), women's knowledge, and physical intimate partner violence (IPV). METHODS AND FINDINGS: We implemented a parallel-cluster-randomized controlled trial, in which 162 villages were randomized into either an intervention arm (UCTs + package of community activities, n = 82) or a control arm (package of community activities only, n = 80). Two different representative samples of children aged 6-29 months and their mothers were surveyed in each arm, one before the intervention in 2014 (control: n = 1,301, intervention: n = 1,357), the other 2 years afterwards in 2016 (control: n = 996, intervention: n = 1,035). Difference-in-differences (DD) estimates of impact were calculated, adjusting for clustering. Children's average age was 17.4 (± 0.24 SE) months in the control arm and 17.6 (± 0.19 SE) months in the intervention arm at baseline. UCTs had a protective effect on HAZ (DD = +0.25 z-scores, 95% confidence interval [CI]: 0.01-0.50, p = 0.039), which deteriorated in the control arm while remaining stable in the intervention arm, but had no impact on stunting (DD = -6.2 percentage points [pp], relative odds ratio [ROR]: 0.74, 95% CI: 0.51-1.06, p = 0.097). UCTs positively impacted both mothers' and children's (18-23 months) consumption of animal source foods (ASFs) (respectively, DD = +4.5 pp, ROR: 2.24, 95% CI: 1.09-4.61, p = 0.029 and DD = +9.1 pp, ROR: 2.65, 95% CI: 1.01-6.98, p = 0.048) and household food insecurity (DD = -10.7 pp, ROR: 0.63, 95% CI: 0.43-0.91, p = 0.016). UCTs did not impact on reported child morbidity 2 week's prior to report (DD = -3.5 pp, ROR: 0.80, 95% CI: 0.56-1.14, p = 0.214) but reduced the financial barrier to seeking healthcare for sick children (DD = -26.4 pp, ROR: 0.23, 95% CI: 0.08-0.66, p = 0.006). Women who received cash had higher odds of delivering in a health facility (DD = +10.6 pp, ROR: 1.53, 95% CI: 1.10-2.13, p = 0.012) and lower odds of giving birth to babies with birth weights (BWs) <2,500 g (DD = -11.8, ROR: 0.29, 95% CI: 0.10-0.82, p = 0.020). Positive effects were also found on women's knowledge (DD = +14.8, ROR: 1.86, 95% CI: 1.32-2.62, p < 0.001) and physical IPV (DD = -7.9 pp, ROR: 0.60, 95% CI: 0.36-0.99, p = 0.048). Study limitations included the short evaluation period (24 months) and the low coverage of UCTs, which might have reduced the program's impact. CONCLUSIONS: UCTs targeting the first "1,000 days" had a protective effect on child's linear growth in rural areas of Togo. Their simultaneous positive effects on various immediate, underlying, and basic causes of malnutrition certainly contributed to this ultimate impact. The positive impacts observed on pregnancy- and birth-related outcomes call for further attention to the conception period in nutrition-sensitive programs. TRIAL REGISTRATION: ISRCTN Registry ISRCTN83330970.

Minimum dietary diversity among women of reproductive age in urban Burkina Faso.

Micronutrient malnutrition is a challenge for women of reproductive age, who are particularly vulnerable due to greater micronutrient needs. The minimum dietary diversity for women (MDD-W) indicator is a micronutrient adequacy's proxy for those women, but little is known about its relation to other dimensions. We assessed MDD-W and its association with other socioeconomic, food security and purchasing practices in urban Burkina Faso. We conducted multi-stage cluster sampling in two main cities of Burkina Faso, stratified by type of district, and interviewed 12 754 women in the 2009-2011 period. We obtained food consumption data through unquantified 24 hour recalls and computed MDD-W as consuming at least five out of ten predefined food groups. We constructed multivariable regression models with sociodemographic and food security covariates. MDD-W in urban Burkina Faso was 31%, higher in Ouagadougou (33%) than in Bobo-Dioulasso (29%), and lower in unstructured districts. The most frequently consumed food groups were 'all starchy', 'vitamin A rich dark green leafy vegetables' and 'other vegetables'. Household's expenses were associated with higher likelihood of MDD-W, while the association with household food security indicators varied by year and type of district. Purchasing foods in markets and choosing the place of purchase based on large choice rather than proximity showed a positive association with the MDD-W. Only one in three women in urban Burkina Faso reached the minimum dietary diversity, and although socioeconomic and food security variables had the greatest effect on MDD-W, purchasing practices, like going to the market, also showed a positive effect.

Multi-criteria Mapping of Stakeholders' Viewpoints in Five Southeast Asian Countries on Strategies to Reduce Micronutrient Deficiencies Among Children and Women of Reproductive Age: Findings from the SMILING Project.

BACKGROUND: Despite scientific evidence on the potential impact or importance of specific interventions to improve micronutrient status of vulnerable groups, political commitment and extensive support from national stakeholders is paramount to support introduction and implementation of these interventions at national level. In order to develop efficient nutritional strategies to improve the micronutrient status of children < 5 years of age and women of reproductive age that will be supported by a wide range of stakeholders, a better understanding of viewpoints on the nutrition politics and strategies is necessary. Multi-criteria mapping (MCM) was successfully used to assess the stakeholder's viewpoint in a wide variety of contexts since the late 1990s. OBJECTIVE: The objective of the present study was to assess the viewpoints of stakeholders on a wide range of potential nutritional interventions in the five Southeast Asian countries participating in the SMILING project. METHOD: MCM methodology was used to appraise the stakeholder's viewpoints in five countries. RESULTS: The results show that the overall stakeholders' preference was for actions already implemented in their country rather than for new, innovative options, even for supplementation. Indirect interventions such like food fortification (except in Indonesia), delayed cord clamping or food-based approaches were generally less favored by the stakeholders. However, the majority of stakeholders agreed that new approaches should be considered and put in place in the future provided that evidence of their impact was demonstrated, that they received adequate technical support for their implementation and their monitoring, and that they will be accompanied by strong advocacy among decision-makers, civil society and beneficiaries. CONCLUSIONS FOR PRACTICE: To conclude, for the introduction of new, innovative strategies to reduce micronutrient deficiencies in South-East Asia, convincing stakeholders appears to be the first hurdle to be taken.

Dissimilarities across age groups in the associations between complementary feeding practices and child growth: Evidence from rural Togo.

Adequate complementary feeding (CF) practices are essential for achieving optimal growth but challenging to measure comprehensively. This paper describes CF practices in 2,034 children aged 6-23 months and investigates their relationships with length-for-age z-score (LAZ) and stunting, using cross-sectional data collected from May to July 2014 in rural Northern Togo. The World Health Organization infant and young child feeding indicators were computed, along with ancillary indicators on feeding style and timing of introduction of complementary foods. The associations between those indicators and children's LAZ and stunting were assessed using linear and logistic regressions after stratification by age group and adjustment for children, maternal, and household characteristics. CF practices were suboptimal, and their associations with child's growth varied across indicators and age groups. In children aged 6-11 months, reaching the minimum dietary diversity and the minimum acceptable diet was associated with higher LAZ (p < .05). In 18- to 23-month-old children, only the consumption of iron-rich food was associated with both LAZ (p = .02) and stunting (p = .05). The late introduction of family foods was associated with higher odds of being stunted and lower LAZ in children aged 12-17 months (p < .001). The untimely introduction of porridge was associated with higher odds of stunting in children aged 9-23 months (p < .05). Unexpectedly, helping the child to eat was negatively associated with linear growth in all age groups. These findings nurture the ongoing process of review of the World Health Organization infant and young child feeding indicators showing that, in their current version, they hardly capture the links between CF and child's growth at different ages.

The SMILING project: a North-South-South collaborative action to prevent micronutrient deficiencies in women and young children in Southeast Asia.

BACKGROUND: The "Sustainable Micronutrient Interventions to Control Deficiencies and Improve Nutritional Status and General Health in Asia" project (SMILING), funded by the European Commission, is a transnational collaboration of research institutions and implementation agencies in five Southeast Asian countries--Cambodia, Indonesia, Laos PDR, Thailand, and Vietnam--with European partners, to support the application of state-of-the art knowledge to alleviate micronutrient malnutrition in Southeast Asia. OBJECTIVE: The major expected outcomes are to improve micronutrient status on a large scale, to identify priority interventions in each Southeast Asian country, and to develop a road map for decision makers and donors for inclusion of these priority interventions into the national policy. METHODS: SMILING has been built around a strong project consortium that works on a constant and proactive exchange of data and analyses between partners and allows for the differences in contexts and development stages of the countries, as well as a strong North-South-South collaboration and colearning. RESULTS: The selection of Southeast Asian countries considered the range of social and economic development, the extent of micronutrient malnutrition, and capacity and past success in nutrition improvement efforts. SMILING is applying innovative tools that support nutrition policy-making and programming. The mathematical modeling technique combined with linear programming will provide insight into which food-based strategies have the potential to provide essential (micro) nutrients for women and young children. Multicriteria mapping will offer a flexible decision-aiding tool taking into account the variability and uncertainty of opinions from key stakeholders. The lessons learned throughout the project will be widely disseminated.

Conditional cash transfer and/or lipid-based nutrient supplement targeting the first 1000 d of life increased attendance at preventive care services but did not improve linear growth in young children in rural Mali: results of a cluster-randomized controlled trial.

BACKGROUND: In 2014, the World Food Programme added to an ongoing health and nutrition program named "Santé Nutritionnelle à Assise Communautaire dans la région de Kayes" (SNACK), the distribution of cash to mothers and/or lipid-based nutrient supplement (LNS) to children aged 6-23 mo, conditional upon attendance at community health centers (CHCs) during the first 1000 d of life. OBJECTIVE: We evaluated the additional impact of the distribution of cash and/or LNS on mean height-for-age z scores (HAZ; primary outcome), stunting (HAZ < -2), and on intermediate outcomes along the program impact pathways. METHODS: In a cluster-randomized controlled trial using a 2 × 2 factorial design, 76 CHCs were randomly assigned to deliver either SNACK, SNACK + Cash, SNACK + LNS, or SNACK + Cash + LNS. Cross-sectional surveys among 12- to 42-mo-old children and their mothers were conducted at baseline (2013, n = 5046) and at endline (2016, n = 5098). RESULTS: Factorial analysis showed no interaction between cash and LNS treatments for HAZ, but found an antagonistic interaction for stunting (OR: 1.55; 95% CI: 1.05, 2.31; P = 0.03). There were no impacts of the cash, LNS, or cash + LNS treatments, compared with the SNACK alone, on either HAZ or stunting (treatment × time interaction). There were significant impacts of the LNS and cash + LNS treatments on attendance at ≥1 growth monitoring (GM) session (OR: 3.95; 95% CI: 1.69, 9.24; OR: 3.90; 95% CI: 1.73, 8.81, respectively) and half the expected sessions (OR: 4.72; 95% CI: 1.47, 15.17; OR: 5.25; 95% CI: 1.82, 15.11, respectively), mothers' knowledge on importance of GM (OR: 1.98; 95% CI: 1.16, 3.39; OR: 3.12; 95% CI: 1.60, 6.09, respectively), and, only for the LNS group, appropriate timing for complementary feeding (OR: 1.62; 95% CI: 1.09, 2.41). CONCLUSIONS: Implementation constraints and suboptimal participation in program activities may explain the lack of impact on child linear growth in this rural region of Mali.This trial was registered at www.isrctn.com as ISRCTN08435964.

The Minimum Dietary Diversity for Women of Reproductive Age (MDD-W) Indicator Is Related to Household Food Insecurity and Farm Production Diversity: Evidence from Rural Mali.

BACKGROUND: The popularity of nutrition-sensitive interventions calls for high-quality monitoring and evaluation tools. In this context, the Minimum Dietary Diversity for Women of Reproductive Age (MDD-W), validated as a proxy of micronutrient adequacy, does fill a gap. However, because it is a newly endorsed indicator, information on its linkages with other dimensions of food and nutrition security is still scarce. OBJECTIVE: The objective of this study was to investigate whether the MDD-W is related to household food insecurity and farm production diversity. METHODS: A cross-sectional survey on a representative sample of 5046 women of reproductive age was conducted in the region of Kayes, Mali, in 2013. Dietary diversity was assessed through qualitative 24-h recall, and MDD-W was computed. MDD-W equaled 1 if the women consumed at least 5 different food groups and 0 otherwise. Food insecurity was measured using the Household Food Insecurity Access Scale and the Household Hunger Scale (HHS), and a farm production diversity score (FPDS) was calculated based on a count of food crops/livestock groups produced. Logistic regressions were used to assess the relation between MDD-W and the indicators of household food security. RESULTS: Only 27% of women reached the MDD-W. These women consumed animal source foods and/or vitamin A-rich vegetables and fruits more frequently than did other women. Women from extremely food insecure households (moderate to severe hunger according to the HHS) were less likely to reach the MDD-W (OR: 0.70; 95% CI: 0.50, 0.97). One more group in the FPDS increased the odds of attaining the MDD-W (OR: 1.12; 95% CI: 1.06, 1.18). CONCLUSION: In the rural region of Kayes, Mali, women's dietary diversity, as measured by the MDD-W, was associated with household-level food security indicators. This study was registered at ISRCTN.org as ISRCTN08435964.

Program Impact Pathway Analysis Reveals Implementation Challenges that Limited the Incentive Value of Conditional Cash Transfers Aimed at Improving Maternal and Child Health Care Use in Mali.

BACKGROUND: The program "Santé Nutritionnelle à Assise Communautaire à Kayes" (SNACK) in Mali aimed to improve child linear growth through a set of interventions targeted to mothers and children during pregnancy and up to the child's second birthday. Distributions of cash to mothers and/or lipid-based nutrient supplement to children 6-23 mo of age were added to SNACK to increase attendance at community health centers (CHCs). OBJECTIVES: The aim of this study, which was embedded in a cluster-randomized impact evaluation of the program, was to assess the incentive value of the cash in relation to CHC attendance. METHODS: We used a mixed-methods approach. We collected quantitative data on cash receipt and CHC attendance in a midline survey of mother-child pairs (n = 3443). A program impact pathway analysis guided qualitative data collection and analysis. Twelve CHCs were purposively selected in study groups that received cash. We conducted semistructured continuous observations of cash distributions in 11 CHCs (n = 22) and semistructured qualitative interviews with frontline workers (FLWs) (n = 71) and mothers (n = 22) who were purposively selected from the midline survey. RESULTS: FLWs' knowledge of the objective and implementation plan of the cash program component was limited. A challenging physical environment and insufficient cash available for each distribution were identified as causes of irregularities in cash distributions. Most mothers mentioned having to return several times to receive their cash. Child health was identified as the main motivation to attend CHCs and cash was described as an additional benefit. CONCLUSION: Implementation constraints related to remoteness and inaccessibility may have undermined the incentive value of the cash transfers in the SNACK program. Additional research is needed to identify interventions that not only incentivize mothers to participate but that can be implemented effectively and with high quality in challenging contexts such as rural areas of Mali.

Has the first implementation phase of the Community Nutrition Project in urban Senegal had an impact?

OBJECTIVE: We evaluated the impact of the Community Nutrition Project (CNP) of Senegal, West Africa on the population. In poor urban districts, the CNP provided underweight 6- to 35-mo-old children with growth monitoring/promotion and food supplementation, and education for mothers for a period of 6 mo. METHODS: A before/after intervention and intervention zone (IZ)/control zone (CZ) design was used to assess whether CNP had an impact 18 mo after it began in Diourbel. Exhaustive samples included children 6-35 mo old in the CZ (n = 895 before and 917 after) and IZ (n = 912 and 759). The impact was assessed by the differential effect of the zone on changes in underweight, wasting, and stunting defined by the threshold of -2 or -3 z scores. RESULTS: The decrease in wasting was higher in the CZ (from 13.7% to 8.6% versus 11.3% to 10.8%, P = 0.042). Changes in stunting did not differ between zones (18.8% to 14.5% versus 15.1% to 14.7%, P = 0.21). However, in the IZ, severe wasting, stunting, and underweight disappeared in children 6-11 mo of age. In the CZ, the socioeconomic data and some outcomes in children reflected a favorable context independent of the CNP. CONCLUSION: Despite a globally satisfactory decrease in malnutrition in the IZ, no impact was demonstrated because the same or an even larger decrease was observed in the CZ, highlighting the importance of relying on a quasi-experimental design. This may be explained in part by weaknesses in the process, which probably interfered with a potential impact, and by the high degree of population mobility, which could have interfered with efficiency assessed on a geographic scale.

Targeting vulnerable households in urban Burkina Faso: effectiveness of geographical criteria but not of proxy-means testing.

The 2007/2008 food prices hike has increased the interest in social safety nets programmes to fight food insecurity. Targeting the most in need is central to achieve effectiveness of such interventions. In 2009 in Ouagadougou, Burkina Faso, a food voucher (FV) programme targeted the 25 000 most vulnerable households (8.3% of the population). Targeting used a two-stage process: first geographical selection of poorest districts (∼90 000 households); then, in those districts, identification of the most vulnerable households according to a proxy-means test (PMT). Targeted households were entitled to receive FV for 1 year. A first survey was conducted at the beginning of the FV distribution on a representative sample of 2273 households drawn from the poorest districts. One year later a second survey, conducted on a subsample of same households (n = 901), identified those who actually received FV (beneficiary). The performance of the whole process was assessed against household food expenditure, used as the reference measure for vulnerability with a cut-off point of 1513 FCFA (corresponding to the 8.3th percentile of the distribution of expenditure). The 'normalized share of transfers going to vulnerable households' (NSTVH), i.e. proportion of FVs allocated to households below the cut-point, was the main criteria of judgement. Almost twice as many FV were allocated to vulnerable households as compared with a theoretical random distribution all over Ouagadougou (NSTVH = 1.85). When considering the sole targeted districts the NSTVH was only 0.84 (i.e. no more effective than a random distribution), meaning that the geographical stage was effective to select vulnerable districts while the PMT did not perform well to identify the most vulnerable households in those districts. Results could have been improved if only targeted households had received FV (NSTVH = 2.61 and 1.18 for the whole Ouagadougou and targeted districts, respectively). Improved targeting procedures or alternate targeting instruments are needed.

African stakeholders' views of research options to improve nutritional status in sub-Saharan Africa.

BACKGROUND: Setting research priorities for improving nutrition in Africa is currently ad hoc and there is a need to shift the status quo in the light of slow progress in reducing malnutrition. This study explored African stakeholders' views on research priorities in the context of environmental and socio-demographic changes that will impact on nutritional status in Africa in the coming years. METHODS: Using Multi-Criteria Mapping, quantitative and qualitative data were gathered from 91 stakeholders representing 6 stakeholder groups (health professionals, food Industry, government, civil society, academics and research funders) in Benin, Mozambique, South Africa, Tanzania, Togo and Uganda. Stakeholders appraised six research options (ecological nutrition, nutritional epidemiology, community nutrition interventions, behavioural nutrition, clinical nutrition and molecular nutrition) for how well they could address malnutrition in Africa. RESULTS: Impact (28.3%), research efficacy (23.6%) and social acceptability (22.4%) were the criteria chosen the most to evaluate the performance of research options. Research on the effectiveness of community interventions was seen as a priority by stakeholders because they were perceived as likely to have an impact relatively quickly, were inexpensive and cost-effective, involved communities and provided direct evidence of what works. Behavioural nutrition research was also highly appraised. Many stakeholders, particularly academics and government were optimistic about the value of ecological nutrition research (the impact of environmental change on nutritional status). Research funders did not share this enthusiasm. Molecular nutrition was least preferred, considered expensive, slow to have an impact and requiring infrastructure. South Africa ranked clinical and molecular nutrition the highest of all countries. CONCLUSION: Research funders should redirect research funds in Africa towards the priorities identified by giving precedence to develop the evidence for effective community nutrition interventions. Expanding research funding in behavioural and ecological nutrition was also valued and require multi-disciplinary collaborations between nutritionists, social scientists, agricultural and climate change scientists.

Sensitivity and specificity of the body mass index to assess low percent body fat in African women.

The objective of this study was to evaluate the ability of the body mass index (BMI, kg/m(2)) to reflect low percent body fat (%BF) in a population with a rather mild but widespread prevalence of low BMI. A sample of 586 women was studied in the Plateau Koukouya, a rural area of the Republic of Congo, Central Africa. Percent BF was estimated from bioelectrical impedance (BIA). BIA parameters were assumed to reflect lean body mass. The correlation between %BF and BMI was high (r = 0.84; P < 0.001). Low %BF or low BIA parameters were defined as the first quartile of the distribution. Sensitivity, specificity, positive and negative predictive value of BMI <18.5, an accepted international cutoff for thinness, in relation to %BF was 58.5%, 93.6%, 75.4%, and 87.1%, respectively. A continuous sensitivity/specificity analysis (receiver operator characteristic [ROC] curves) for characterizing low %BF or low BIA parameters was done for a large range of BMI values. ROC curve analysis for %BF suggested that an acceptable trade-off between sensitivity (89.8%) and specificity (77.9%) occurred at a BMI of 19.7 kg/m(2). However, the positive predictive value was low (57.6%). For the prediction of low BIA parameters, results were similar, showing moderate sensitivity and high specificity for BMI <18.5, a cutoff point of BMI = 19.6, and low positive predictive values (<48%). The data suggest that BMI was not a good predictor of low %BF. This is consistent with the assumption of a decrease in both fat and fat free body mass in cases of low BMI. Am. J. Hum. Biol. 12:25-31, 2000. Copyright 2000 Wiley-Liss, Inc.

Developing national obesity policy in middle-income countries: a case study from North Africa.

BACKGROUND: The prevalence of overweight and obesity is a rapidly growing threat to public health in both Morocco and Tunisia, where it is reaching similar proportions to high-income countries. Despite this, a national strategy for obesity does not exist in either country. The aim of this study was to explore the views of key stakeholders towards a range of policies to prevent obesity, and thus guide policy makers in their decision making on a national level. METHODS: Using Multicriteria Mapping, data were gathered from 82 stakeholders (from 33 categories in Morocco and 36 in Tunisia) who appraised 12 obesity policy options by reference to criteria of their own choosing. RESULTS: The feasibility of policies in practical or political terms and their cost were perceived as more important than how effective they would be in reducing obesity. There was most consensus and preference for options targeting individuals through health education, compared with options that aimed at changing the environment, i.e. modifying food supply and demand (providing healthier menus/changing food composition/food sold in schools); controlling information (advertising controls/mandatory labelling) or improving access to physical activity. In Tunisia, there was almost universal consensus that at least some environmental-level options are required, but in Morocco, participants highlighted the need to raise awareness within the population and policy makers that obesity is a public health problem, accompanied by improving literacy before such measures would be accepted. CONCLUSION: Whilst there is broad interest in a range of policy options, those measures targeting behaviour change through education were most valued. The different socioeconomic, political and cultural contexts of countries need to be accounted for when prioritizing obesity policy. Obesity was not recognized as a major public health priority; therefore, convincing policy makers about the need to prioritize action to prevent obesity, particularly in Morocco, will be a crucial first step.

Process evaluation of the Senegal-Community Nutrition Project: an adequacy assessment of a large scale urban project.

OBJECTIVE: Although essential for understanding the reasons for success or failure of large scale nutritional interventions, process evaluation results are rarely reported. Our objective was to assess whether the process output objectives of the Community Nutrition Project (CNP) in Senegal, West Africa, were adequately met. METHODS: An adequacy assessment study based on monitoring data for individuals collected during the CNP was used to assess 'fidelity', 'extent' and 'reach' of participants recruitment and of the services provided. The CNP provided underweight or nutritionally at risk 6- to 35-month-old children in poor districts with monthly growth monitoring and promotion and a weekly food supplementation for 6 month periods, provided that mothers attended weekly nutrition education sessions. An exhaustive sample of the participating children (n = 4084) in Diourbel was used for evaluation over the first 2 years. RESULTS: At recruitment, only 66% of children were underweight (vs. 90% expected) varying with the CNP center and cohort, and the child's sex and age. Attendance at growth monitoring reached expected levels (93%vs. 90%) whereas numbers of food supplements distributed and education sessions attended were lower than expected (45%vs. 90% and 62%vs. 80%, respectively). At the end of follow-up, 61% of underweight children recovered vs. 80% expected. CONCLUSIONS: Because of CNP design for underweight diagnosis and bias in the targeting process, respect for selection criteria was low and consequently under coverage and leakage occurred. Besides a globally satisfactory process, wide discrepancies were observed between CNP centres concerning the utilization and effectiveness of services. This formative evaluation helped diagnose weaknesses; ongoing feedback enabled the CNP to improve targeting and supply of supplements. It also informed a larger impact evaluation. Some generalizable lessons for similar programmes have been highlighted.

An infant and child feeding index is associated with the nutritional status of 6- to 23-month-old children in rural Burkina Faso.

The measurement of child feeding practices is complex and the relation between the quality of feeding and children's nutritional status is difficult to establish. We examined this relation in rural Burkina Faso, West Africa, using an adapted version of the Infant and Child Feeding Index (ICFI). A cross-sectional study was conducted on a random sample of children (n = 2466) aged 6-35 mo in 2002. Feeding practices were assessed through a qualitative 24-h recall. ICFIs were made age specific for children aged 6-11 mo (n = 614), 12-23 mo (n = 987), 24-35 mo (n = 865), and were divided into terciles. The association between height-for-age Z-scores (HAZ), weight-for-height Z-scores (WHZ), and ICFIs were examined separately in each age group. Multivariate analyses were performed to control for sociodemographic and economic factors. Adjusted mean HAZ in low, medium, and high categories of ICFI were, respectively, -1.67, -1.53, and -1.21 (P = 0.003) among children aged 6-11 mo; -2.54, -2.24, and -2.11 (P = 0.0002) among children aged 12-23 mo; and -2.18, -2.20, and -2.45 (P = 0.05) among children aged 24-35 mo. There was also a positive association between ICFI and WHZ in children aged 12-23 mo (P = 0.05) but a negative association in children aged 6-11 mo (P = 0.02). Among the components of ICFI, dietary diversity or variety scores and frequency of meals or snacks supported the positive associations with anthropometric indices, except for WHZ in children aged 6-11 mo, whereas breast-feeding exhibited a reverse association among older children. A suitable ICFI and/or some of its components could be used to identify vulnerable age groups and to monitor interventions in similar rural areas of Africa.