How does social desirability bias influence survey-based estimates of the use of antenatal care in rural Nepal? A validation study.

OBJECTIVES: Social desirability bias is often speculated to influence survey responses but seldom studied in healthcare. The objective was to explore whether social desirability scores (SDS) or the presence of interview observers is associated with inaccurate recall and overestimation of antenatal care (ANC) services. DESIGN: Longitudinal validation study comparing recalled receipt of ANC services and nutrition components of ANC against direct observations of care. An adapted short form Marlowe-Crowne questionnaire was used to generate an SDS, and the presence of interview observers was treated as a separate exposure. We assessed accuracy and overestimation of recalled receipt of ANC services against observed receipt using log-binomial regression, adjusting for age, education, first-pregnancy and socioeconomic status. SETTING: Rural Southern Nepal with recruitment from five government health posts. PARTICIPANTS: 401 pregnant women. RESULTS: Social desirability scores did not significantly predict accuracy or overestimation of most types of ANC care except counselling on nausea. Higher SDS was associated with more accurate recall (adjusted RR, aRR 1.08 (95% CI 1.03, 1.12)) and less overestimation (aRR 0.85 (0.80, 0.91)). The presence of mothers-in-law or husbands during interviews was associated with greater overestimation of the number of ANC visits received by more than three visits (aRR 2.07 (1.11, 3.84)) and (aRR 4.19 (2.17, 8.10)), respectively. Those interviewed with friends present tended to overestimate the receipt of counselling on nausea, avoiding alcohol and not smoking. CONCLUSION: The presence of observers can lead to overestimation of the receipt of ANC care and support the conduct of interviews in private settings despite challenges of doing so in village contexts. Findings that the SDS did not predict the accuracy of most types of ANC care might reflect a reality that such questions may not be sensitive from a social-norms perspective. Additional local adaptation of SDS is recommended.

Critical assessment of the current indicator for antenatal iron-containing supplementation coverage: Insights from a mixed-methods study.

Daily consumption of iron-containing supplements is recommended for all pregnant women but there is no approved global standard indicator for assessing supplementation coverage. Furthermore, the validity of commonly used coverage indicators for iron-containing supplement consumption is questionable. The WHO-UNICEF Technical Expert Advisory Group on Nutrition Monitoring, and partners, have systematically worked to identify a feasible and valid indicator of iron-containing supplement coverage for reporting by countries. In 2019, we conducted key informant interviews with respondents in eight countries, fielded an online survey (in three languages using SurveyMonkey) to which 142 nutrition professionals from 52 countries responded, and used Demographic and Health Surveys (DHS) data from four countries to assess determinants of the quality of iron-containing supplement coverage data. Less than half (45%) of online survey respondents were satisfied with the current methods for collecting iron-containing supplement coverage data in their context. Recommended changes by study respondents include recall period <5 years, adding questions about counselling, including other beneficiary groups, and assessing supply chain functionality. The DHS analysis suggested an association between time since pregnancy and data quality. Data heaping on multiples of 30 was observed in 40%-75% of data. There is a clear demand for a revised indicator and measurement guidance for coverage of iron-containing supplementation during pregnancy. Future research should continue the development and validation of a global indicator, to more precisely validate the quality of recall data, including the distinction between distribution and consumption using various question formulations.

Design Factors for Food Supplementation and Nutrition Education Interventions That Limit Conclusions about Effectiveness for Wasting Prevention: A Scoping Review of Peer-Reviewed Literature.

We conducted a scoping review to characterize the evidence base for the effectiveness of food supplementation (FS), nutrition education (NE), or FS/NE interventions to prevent wasting among children aged 6 to 59 mo. We aimed to identify gaps in peer-reviewed literature and to develop recommendations for strengthening study designs. We identified 56 unique studies (FS = 21, NE = 19, FS/NE = 16) for which we assessed intervention design factors, implementation context, evaluation methods, and wasting impact. Compared with studies focused on stunting, fewer wasting-focused studies reported weight-for-height z score (WHZ). Midupper arm circumference (MUAC) was more commonly reported in wasting-focused studies (71.4%) than those focused on stunting (36.8%) or wasting and stunting (30.4%). FS studies measured anthropometry (mean, 95% CI) more frequently at every 11.3 (7.8, 14.8) wk than NE interventions at 36.3 (8.8, 62.1) wk (P = 0.036), but not FS/NE interventions at 25.8 (5.6, 49.1) wk (P = 0.138). NE interventions tended to be of longer duration than FS or FS/NE interventions. Only 6 studies followed and measured children after the intervention period ended. Across all studies, 45% reported a significant effect on wasting; these included FS, NE, and FS/NE interventions. The lack of comparability across studies limits conclusions about the effectiveness of specific types of interventions. To build a more unified evidence base for wasting prevention we recommend that future studies 1) report on a consistent set of metrics, including MUAC; 2) attempt to measure change in wasting incidence using more frequent measures; 3) measure wasting prevalence among the general population; 4) follow children postintervention to assess relapse; 5) measure food insecurity and diet quality; and 6) use harmonized protocols across multiple settings. Such efforts to improve study comparability will strengthen the evidence base, may help unite divergent professional communities, and ultimately accelerate progress toward eliminating child undernutrition.

Independent Evaluation of the integrated Community Case Management of Childhood Illness Strategy in Malawi Using a National Evaluation Platform Design.

We evaluated the impact of integrated community case management of childhood illness (iCCM) on careseeking for childhood illness and child mortality in Malawi, using a National Evaluation Platform dose-response design with 27 districts as units of analysis. "Dose" variables included density of iCCM providers, drug availability, and supervision, measured through a cross-sectional cellular telephone survey of all iCCM-trained providers. "Response" variables were changes between 2010 and 2014 in careseeking and mortality in children aged 2-59 months, measured through household surveys. iCCM implementation strength was not associated with changes in careseeking or mortality. There were fewer than one iCCM-ready provider per 1,000 under-five children per district. About 70% of sick children were taken outside the home for care in both 2010 and 2014. Careseeking from iCCM providers increased over time from about 2% to 10%; careseeking from other providers fell by a similar amount. Likely contributors to the failure to find impact include low density of iCCM providers, geographic targeting of iCCM to "hard-to-reach" areas although women did not identify distance from a provider as a barrier to health care, and displacement of facility careseeking by iCCM careseeking. This suggests that targeting iCCM solely based on geographic barriers may need to be reconsidered.

Iron supplementation of young children: learning from the new evidence.

High iron needs and low-iron diets combine to make early childhood one of the highest risk periods for iron deficiency. Recommendations for iron supplementation for this age group have been based on positive effects on anemia and child development. In contrast, the evidence regarding growth and morbidity outcomes has been equivocal, with some evidence of risk. The new evidence from Nepal and Zanzibar is reviewed, and possible interpretations are discussed. The Zanzibar trial found significant adverse effects in the overall population with poor malaria services and substantial benefit to iron-deficient children (the majority) in an area where access to treatments was provided. Cost-effectiveness analysis suggests that targeting supplements to iron-deficient children in Zanzibar may not increase costs (relative to universal supplementation) and would increase benefit. Operations research is needed to test this. We conclude with three options for maximizing the benefits and minimizing the risks of iron supplements.