Using formative research to design context-specific animal source food and multiple micronutrient powder interventions to improve the consumption of micronutrients by infants and young children in Tanzania, Kenya, Bangladesh and Pakistan.

Optimal complementary feeding practices including consumption of multiple micronutrient powders (MNP) are recommended to improve micronutrient intake by infants and young children (IYC) 6-23 months. Formative research was used to design the behaviour change strategy to improve IYC micronutrient intake for the multicountry ENRICH project in rural impoverished areas of Tanzania, Kenya, Bangladesh and Pakistan. Employing a qualitative approach with multiple methods and guided by a social ecological framework, the study was conducted in several phases: data collection in the community, household and health facilities, initial analysis and household trials (HHT). Results found limited use of animal source foods (ASF) for feeding IYC and MNP largely unavailable. Although cost constrained access to ASF, potential more affordable context-specific ASF options were identified in each setting. Caregivers associated ASF with many positive attributes for IYC, but barriers to feeding them included lack of caregiver time and knowledge of specific preparation techniques, and limited advice from health workers. Feeding practices were identified that used time-efficient, specific preparations for eggs and other ASF, and demonstrated good initial acceptability and feasibility during HHT. Testing MNP in HHT found good initial feasibility and acceptability and provided an understanding of the facilitators and constraints for preparing, feeding and promoting MNP. In conclusion, formative research led to the design of context-specific ASF and MNP complementary feeding promotion strategies to improve IYC consumption of micronutrients by identifying the practices, benefits, motivations and alternative actions to overcome the barriers in each setting.

Formative research to explore the acceptability and use of infant food grinders for the promotion of animal source foods and micronutrient powders in rural Peru.

According to global recommendations, quality diets for complementary feeding (CF) should include a diversity of foods including vitamin A-rich fruits and vegetables and sources of high-quality proteins and essential nutrients, particularly animal-source foods (ASF). A key barrier to feeding ASF surrounds beliefs that the preparation of foods of a thicker consistency may cause problems of digestion, "heaviness" or stomach problems, swallowing, and choking. The objective of this study was to explore, through systematic formative research, the acceptability, use, and feasibility of a simple technology, commercial infant food grinders, in two rural Peruvian settings where there is delayed and low consumption of complementary foods of a thick consistency, including ASF. Phase I explored the barriers, constraints, and opportunities related to the provision of foods of a thicker consistency with a focus on ASF. Phase II encompassed household behavioural trials with mothers and infants to assess the acceptability and use of the grinders in the home setting, using key concepts and messages developed from the information obtained during Phase I. The technology was highly acceptable, used by the majority of mothers (87.8%), and led to changes in cultural perceptions, facilitating increased feeding of appropriate textures (thick purees), ASF, and multimicronutrient powders. Energy, protein, and micronutrient intakes were all significantly greater after the household behavioural trials. This simple technology, paired with systematic formative research to appropriately promote its use across cultures, may have a significant effect on improving CF practices globally, particularly for young infants beginning CF at 6 months.

Strengthening health services to deliver nutrition education to promote complementary feeding and healthy growth of infants and young children: formative research for a successful intervention in peri-urban Trujillo, Peru.

Formative research is critical for developing effective nutrition-specific interventions to improve infant and young child (IYC) feeding practices and promote healthy growth. Health workers interact with caregivers during health facility visits, yet there is limited research about how to optimize delivery of such interventions during these visits. The extensive reach of IYC health services globally calls for research to address this gap. In Trujillo, Peru, formative research was conducted to explore complementary feeding practices with caregivers as well as health worker routines and interactions with caregivers related to feeding and healthy growth; results informed the development and delivery of an educational intervention. Multiple qualitative methods were used to collect data on a purposive sample of health workers and caregivers from three health facilities and communities: household trials followed. Complementary feeding messages with doable behaviours were developed, and three were selected as key to promote based on their nutritional impact and cultural acceptability. In the health facilities, medical consultation, well-child visits and nutrition consultation all dealt with aspects of IYC nutrition/growth during their interactions with caregivers but were independent and inconsistent in approach. A nutrition education strategy was developed based on consistency, quality and coverage in the IYC health services. We conclude that formative research undertaken in the community and IYC health services was critical to developing a successful and culturally relevant intervention to promote optimal complementary feeding practices and healthy growth during interactions between health workers and caregivers at routine health facility visits. © 2016 John Wiley & Sons Ltd.

Promoting multi-micronutrient powders (MNP) in Peru: acceptance by caregivers and role of health personnel.

UNLABELLED: Iron deficiency causes anaemia and other adverse effects on the nutritional status and development of millions of children. Multi-micronutrient powders (MNP) have been shown to reduce anaemia in young children. In Peru, 50% of children 6-36 months are anaemic. Since 2009, the government has started distributing MNP. This qualitative study explored the acceptability of MNP by caregivers and the role of health personnel (HP) in three regions (Apurimac, Ayacucho and Cajamarca), piloting the MNP programme between 2009 and 2011. Data collection consisted of interviews (35) and observations (13) with caregivers and HP (11). In Cajamarca, 16 families were visited three times in their homes to understand caregivers' use and difficulties. Results showed the critical role HP has in influencing caregiver understanding and use of the MNP, as well as the need for training to avoid confusing messages and provide counselling techniques that consider cultural sensitivity to optimize HP interactions with caregivers and adapt the recommendations for MNP use to local family feeding routines. There was greater acceptance of MNP by caregivers giving semi-solid foods (e.g. purees) to their children than those who served dilute preparations (e.g. soups). Acceptance was similar across regions, but there were some differences between urban and rural settings. Home visits were shown to be a key in improving the use of MNP by caregivers as misunderstandings on preparation, required consistency and optimum practices were common. These findings can contribute to strategies to enhance acceptability and use. KEY MESSAGES: Acceptance and use of multi-micronutrient powders (MNP) by caregivers greatly depend upon how it is presented, promoted and counselled by health personnel. Counselling for MNP use needs to consider and adapt to the local cultural context and incorporate family and child feeding routines. MNP are presented as part of appropriate feeding practices, encouraging caregivers to find simple and acceptable ways of giving semi-solid or solid foods with which to mix it.

Formative research methods for designing culturally appropriate, integrated child nutrition and development interventions: an overview.

Nutritional and developmental insults in the first few years of life have profound public health implications, including substantial contributions to neonatal, infant, and early childhood morbidity and mortality, as well as longer term effects on cognitive development, school achievement, and worker productivity. Optimal development that can lead to the attainment of an individual's fullest potential, therefore, requires a combination of genetic capacity, adequate nutrition, psychosocial stimulation, and safe, clean physical environments. Researchers and policymakers have called for integrated child nutrition and development interventions for more than 20 years, yet there are only a handful of efficacy trials and even fewer examples of integrated interventions that have been taken to scale. While a critical component in the design of such interventions is formative research, there is a dearth of information in both the literature and policy arenas to guide this phase of the process. To move the field forward, this paper first provides an overview of formative research methods with a focus on qualitative inquiry, a description of the critical domains to be assessed (infant and young child feeding, responsive feeding, and child development), and currently available resources. Application of these methods is provided through a real-world case study--the design of an integrated nutrition and child development efficacy trial in Andhra Pradesh, India. Recommendations for next steps are discussed, the most important of which is the need for a comprehensive set of formative guidelines for designing locally tailored, culturally appropriate, integrated interventions.

Cluster-randomized trial on complementary and responsive feeding education to caregivers found improved dietary intake, growth and development among rural Indian toddlers.

Inadequate feeding and care may contribute to high rates of stunting and underweight among children in rural families in India. This cluster-randomized trial tested the hypothesis that teaching caregivers appropriate complementary feeding and strategies for how to feed and play responsively through home-visits would increase children's dietary intake, growth and development compared with home-visit-complementary feeding education alone or routine care. Sixty villages in Andhra Pradesh were randomized into three groups of 20 villages with 200 mother-infant dyads in each group. The control group (CG) received routine Integrated Child Development Services (ICDS); the complementary feeding group (CFG) received the ICDS plus the World Health Organization recommendations on breastfeeding and complementary foods; and the responsive complementary feeding and play group (RCF&PG) received the same intervention as the CFG plus skills for responsive feeding and psychosocial stimulation. Both intervention groups received bi-weekly visits by trained village women. The groups did not differ at 3 months on socioeconomic status, maternal and child nutritional indices, and maternal depression. After controlling for potential confounding factors using the mixed models approach, the 12-month intervention to the CFG and RCF&PG significantly (P < 0.05) increased median intakes of energy, protein, Vitamin A, calcium (CFG), iron and zinc, reduced stunting [0.19, confidence interval (CI): 0.0-0.4] in the CFG (but not RCF&PG) and increased (P < 0.01) Bayley Mental Development scores (mean = 3.1, CI: 0.8-5.3) in the RCF&PG (but not CFG) compared with CG. Community-based educational interventions can improve dietary intake, length (CFG) and mental development (RCF&PG) for children under 2 years in food-secure rural Indian families.

Infant and young child feeding in the Peruvian Amazon: the need to promote exclusive breastfeeding and nutrient-dense traditional complementary foods.

The study objective was to understand the role of traditional Awajún foods in dietary quality and the potential impacts on growth of Awajún infants and young children 0-23 months of age. Research took place in April and May of 2004, along the Cenepa River in six Awajún communities. Anthropometry estimated nutritional status for 32 infants (0-23 months). Repeat dietary recalls and infant feeding histories were completed with 32 mothers. Adequacy of the complementary foods was compared with World Health Organization guidelines. Anthropometry indicated a high prevalence of stunting (39.4% of infants and young children), with nutritional status declining with age. Half of the Awajún mothers practised exclusive breastfeeding. Dietary recalls and infant food histories suggested that many of the infants were getting adequate nutrition from complementary foods and breastfeeding; however, there was variation in breastfeeding and complementary feeding practices among the mothers. Complementary feeding for young children 12-23 months generally met nutrient recommendations, but mean intakes for iron, zinc, calcium and vitamin A were inadequate in infants 6-11 months. Traditional foods provided 85% of energy and were more nutrient dense than market foods. Appropriate infant and complementary feeding was found among some women; however, given the range of feeding practices and introduction of market foods, health promotion targeting infant and young child feeding is warranted.

Effect of a two-component intervention to change hospital practice from early to delayed umbilical cord clamping in the Peruvian Amazon.

OBJECTIVE: To investigate the effect of a two-component intervention to change hospital practice with regard to the timing of umbilical cord clamping. METHODS: A pre-/post-study design was used to measure the effect of a two-component intervention on mean time to clamp the umbilical cord. The study took place at Hospital Iquitos "César Garayar García" in Iquitos, Peru. A total of 224 women were recruited from the hospital labor room: 112 pre-intervention, from 18 May-3 June 2009, and 112 post-intervention, from 6-20 July 2009. The intervention consisted of 1) a "best practice" three-day training workshop on birthing, and 2) a hospital directive. All deliveries were observed and the time between delivery of the first shoulder and clamping of the umbilical cord was measured with a digital stopwatch. RESULTS: The mean time between delivery and cord clamping before the intervention was 56.8 seconds (95% confidence interval [CI]: 51.0, 62.7). This increased to 169.8 seconds (95% CI: 153.8, 185.8) following the intervention. The difference in mean time to clamp remained significant in multivariate analyses (ß adjusted = 113.2 seconds, 95% CI: 96.6, 129.9). CONCLUSIONS: Hospital policy and practice can be successfully changed from early to delayed umbilical cord clamping using a simple, two-component intervention.

Effect of a two-component intervention to change hospital practice from early to delayed umbilical cord clamping in the Peruvian Amazon / Efecto de una intervención de dos componentes para modificar la práctica hospitalaria de pinzamiento del cordón umbilical de precoz a tardío en la Amazonia peruana

OBJECTIVE: To investigate the effect of a two-component intervention to change hospital practice with regard to the timing of umbilical cord clamping. METHODS: A pre-/post-study design was used to measure the effect of a two-component intervention on mean time to clamp the umbilical cord. The study took place at Hospital Iquitos "César Garayar García" in Iquitos, Peru. A total of 224 women were recruited from the hospital labor room: 112 pre-intervention, from 18 May-3 June 2009, and 112 post-intervention, from 6-20 July 2009. The intervention consisted of 1) a "best practice" three-day training workshop on birthing, and 2) a hospital directive. All deliveries were observed and the time between delivery of the first shoulder and clamping of the umbilical cord was measured with a digital stopwatch. RESULTS: The mean time between delivery and cord clamping before the intervention was 56.8 seconds (95 percent confidence interval [CI]: 51.0, 62.7). This increased to 169.8 seconds (95 percent CI: 153.8, 185.8) following the intervention. The difference in mean time to clamp remained significant in multivariate analyses (βadjusted = 113.2 seconds, 95 percent CI: 96.6, 129.9). CONCLUSIONS: Hospital policy and practice can be successfully changed from early to delayed umbilical cord clamping using a simple, two-component intervention.

OBJETIVO: Investigar el efecto de una intervención de dos componentes para modificar la práctica hospitalaria respecto del momento en que se practica el pinzamiento del cordón umbilical. MÉTODOS: Se empleó un estudio con diseño antes-después para medir el efecto de una intervención de dos componentes sobre el tiempo medio de pinzamiento del cordón umbilical. El estudio se llevó a cabo en el Hospital Iquitos "César Garayar Gar-cía" en Iquitos (Perú). Se incluyeron en total 224 mujeres atendidas en la sala de trabajo de parto del hospital: 112 antes de la intervención, entre el 18 de mayo y el 3 de junio del 2009, y 112 después de la intervención, entre el 6 y el 20 de julio del 2009. La intervención consistió en: 1) un taller de capacitación sobre las "mejores prácticas" en la atención del parto, de 3 días de duración y 2) una directiva del hospital. Se observaron todos los partos y se midió el tiempo entre la salida del hombro anterior y el pinzamiento del cordón umbilical con un cronómetro digital. RESULTADOS: El tiempo medio entre el parto y el pinzamiento del cordón antes de la intervención fue de 56,8 segundos (intervalo de confianza [IC] de 95 por cento: 51,0-62,7), y aumentó a 169,8 segundos (IC 95 por cento: 153,8-185,8) después de la intervención. La diferencia en el tiempo medio hasta el pinzamiento siguió siendo significativa en los análisis multivariados (βajustado = 113,2 segundos, IC 95 por cento: 96,6-129,9). CONCLUSIONES: Es posible cambiar las normas y las prácticas hospitalarias de pinzamiento del cordón umbilical de precoz a tardío mediante una intervención sencilla de dos componentes.

Acceptability and safety of novel infant porridges containing lyophilized meat powder and iron-fortified wheat flour.

BACKGROUND: Lyophilized meat powder with iron-fortified wheat flour can be used to produce an infant porridge with bioavailable iron, but its acceptability and safety are unknown. OBJECTIVE: To evaluate the acceptability and safety of porridges containing lyophilized meat powder and iron-fortified wheat flour. METHODS: Peruvian mothers' input was used to develop porridges without (no meat) and with meat powder (low or high chicken liver, low or high chicken thigh). Acceptability was determined by maternal hedonic scoring, 9-day infant intake, and videotape analysis of how well infants liked each porridge. Dry and cooked porridges and meat ingredients were tested for microorganisms; meats were tested for pesticides. RESULTS: Mothers gave higher acceptability scores to the no-meat porridge, followed in order by low and high quantities of meat powder (e.g., mean +/- SD "taste"scores were 4.5 +/- 0.9 for the no-meat, 3.7 +/- 1.1 for the low-liver, and 3.3 +/- 1.1 for the high-liver porridges, p = .0001). Infants' porridge intake did not differ: 61.4 +/- 47.1 g of no-meat, 62.1 +/- 44.9 g of low-thigh, and 67.5 +/- 42.0 g of low-liver (p = .7), as supported by the video analysis. Microbiologic safety was acceptable except for marginally acceptable molds and yeasts in dry ingredients. No pesticide residues were detected. CONCLUSIONS: Despite mothers' clear preference for no-meat porridges, infants consumed equal amounts of porridges with and without meat. Thus, if mothers can be convinced to feed the meat-containing porridges to the infants despite their own preferences, the infants will consume these porridges. The mold and yeast content of the porridge ingredients must be reduced.

Maternal education and intelligence predict offspring diet and nutritional status.

The traditional assumption that children's nutritional deficiencies are essentially due either to overall food scarcity or to a lack of family resources to purchase available food has been increasingly questioned. Parental characteristics represent 1 type of noneconomic factor that may be related to variability in children's diets and nutritional status. We report evidence on the relation of 2 parental characteristics, maternal education level and maternal intelligence, to infant and toddler diet and nutritional status. Our sample consisted of 241 low-income Peruvian mothers and their infants assessed from 3 to 12 mo, with a further follow-up of 104 of these infants at 18 mo of age. Using a nonexperimental design, we related measures of level of maternal education, maternal intelligence, and family socioeconomic status to infant anthropometry, duration of exclusive breast-feeding, adequacy of dietary intake, and iron status. Results indicated unique positive relations between maternal education level and the extent of exclusive breast-feeding. Significant relations between maternal education and offspring length were partially mediated by maternal height. There also were unique positive relations between maternal intelligence and quality of offspring diet and hemoglobin level. All findings remained significant even after controlling for family socioeconomic characteristics. This pattern of results illustrates the importance of parental characteristics in structuring the adequacy of offspring diet. Maternal education and intelligence appear to have unique influences upon different aspects of the diet and nutritional status of offspring.

Effectiveness of an educational intervention delivered through the health services to improve nutrition in young children: a cluster-randomised controlled trial.

BACKGROUND: Malnutrition is the underlying cause of half of child mortality. Many programmes attempt to remedy this issue but there is a lack of evidence on effective ways to decrease child malnutrition. METHODS: We did a cluster-randomised trial of an educational intervention in a poor periurban area (ie, shanty town) of Peru. Guided by formative research, the intervention aimed to enhance the quality and coverage of existing nutrition education and to introduce an accreditation system in six government health facilities compared with six control facilities. The primary outcome measure was growth that was measured by weight, length, and Z scores for weight-for-age and length-for-age at age 18 months. Main secondary outcomes were the percentage of children receiving recommended feeding practices and the 24-h dietary intake of energy, iron, and zinc from complementary food at ages 6, 9, 12, and 18 months. Analysis was by intention to treat. FINDINGS: We enrolled a birth cohort of 187 infants from the catchment areas of intervention centres and 190 from control areas. Caregivers in intervention areas were more likely to report receiving nutrition advice from the health service than were caregivers in control health facilities (16 [52%] of 31 vs 9 [24%] of 37, p=0.02). At 6 months more babies in intervention areas were fed nutrient-dense thick foods at lunch (a recommended complementary feeding practice) than were controls (48 [31%] of 157 vs 29 [20%] of 147; difference between groups 19 [11%], p=0.03). Fewer children in intervention areas failed to meet dietary requirements for energy (8 months: 30 [18%] of 170 vs 45 [27%] of 167, p=0.04; 12 months: 64 [38%] of 168 vs 82 [49%] of 167, p=0.043), iron (8 months: 155 [91%] of 170 vs 161 [96%] of 167, 9 months: 152 [93%] of 163 vs 165 [99%] of 166, p=0.047), and zinc (9 months: 125 [77%] of 163 vs 145 [87%] of 166, p=0.012) than did controls. Children in control areas were more likely to have stunted growth (ie, length for age less than 2 SD below the reference population median) at 18 months than children in intervention groups (26 [16%] of 165 vs 8 [5%] of 171; adjusted odds ratio 3.04 [95% CI 1.21-7.64]). Adjusted mean changes in weight gain, length gain, and Z scores were all significantly better in the intervention area than in the control area. INTERPRETATION: Improvement of nutrition education delivered through health services can decrease the prevalence of stunted growth in childhood in areas where access to food is not a limiting factor.