The Cost and Cost-Effectiveness of an Integrated Wasting Prevention and Screening Intervention Package in Burkina Faso and Mali.

BACKGROUND: Little is known about costs and cost effectiveness of interventions that integrate wasting prevention into screening for child wasting. OBJECTIVES: This study's objective was to estimate the cost and cost-effectiveness of an intervention that integrated behavior change communication (BCC) and small-quantity lipid-based nutrient supplements (SQ-LNS) into platforms for wasting screening in Burkina Faso (a facility-based platform, where BCC was enhanced compared with standard care) and Mali (a community-based platform, with standard BCC). METHODS: Activity-based costing was used to estimate the cost per child-contact for the intervention and the comparison group, which did not receive the intervention. Costs were ascertained from accounting records, interviews, surveys, and observations. The number of child-contacts was calculated using population size estimates and average attendance rates for each service. Costs per disability-adjusted life year (DALY) averted were estimated using a Markov model populated with data from the parent trials on impact of wasting incidence and treatment coverage. RESULTS: In the intervention group in Burkina Faso, the cost per child-contact of facility-based screening was $0.85 of enhanced BCC was $4.28, and of SQ-LNS was $8.86. In Mali, the cost per child-contact of community-based screening was $0.57, standard BCC was $0.72, and SQ-LNS was $4.14. Although no SQ-LNS costs were incurred in the comparison groups (hence lower total costs), costs per child-contact for screening and BCC were higher because coverage of these services was lower. The intervention package cost $1073 per DALY averted in Burkina Faso and $747 in Mali. CONCLUSIONS: Integration of wasting prevention into screening for child wasting led to higher total costs but lower unit costs than standard screening due to increased coverage. Greater cost-effectiveness could be achieved if BCC were strengthened and led to improved caregiver health and nutrition practices and if screening triggered appropriate use of services and higher treatment coverage.

Specialized and versatile antisocial behavioral profiles in preschoolers: Associations with persistent behavioral problems.

This study investigated specialized and versatile antisocial patterns in preschoolers and examined the link between these patterns and the risk of developing chronic antisocial behaviors throughout childhood. A total of 556 children (50.6% boys, 88% White) participated in this three-wave longitudinal study at 3-5, 6-8, and 10-12 years old. A latent transition analysis revealed that most preschoolers (89.5%) who adopt several subtypes of antisocial behaviors simultaneously exhibit stable and severe antisocial behaviors throughout childhood. In contrast, most preschoolers (60%) who favor one specific subtype of antisocial behaviors desist from such behaviors between preschool and preadolescence. Importantly, aggression accompanied by other subtypes of antisocial behaviors predicted chronicity better than aggression alone, casting doubt on the notion that aggression is the strongest predictor of chronicity.

Effects of an integrated poultry value chain, nutrition, gender and WASH intervention (SELEVER) on hygiene and child morbidity and anthropometry in Burkina Faso: A secondary outcome analysis of a cluster randomised trial.

Nutrition-sensitive agriculture programmes have the potential to improve child nutrition outcomes, but livestock intensification may pose risks related to water, sanitation and hygiene (WASH) conditions. We assessed the impact of SELEVER, a nutrition- and gender-sensitive poultry intervention, with and without added WASH focus, on hygiene practices, morbidity and anthropometric indices of nutrition in children aged 2-4 years in Burkina Faso. A 3-year cluster randomised controlled trial was implemented in 120 villages in 60 communes (districts) supported by the SELEVER project. Communes were randomly assigned using restricted randomisation to one of three groups: (1) SELEVER intervention (n = 446 households); (2) SELEVER plus WASH intervention (n = 432 households); and (3) control without intervention (n = 899 households). The study population included women aged 15-49 years with an index child aged 2-4 years. We assessed the effects 1.5-years (WASH substudy) and 3-years (endline) post-intervention on child morbidity and child anthropometry secondary trial outcomes using mixed effects regression models. Participation in intervention activities was low in the SELEVER groups, ranging from 25% at 1.5 years and 10% at endline. At endline, households in the SELEVER groups had higher caregiver knowledge of WASH-livestock risks (∆ = 0.10, 95% confidence interval [CI] [0.04-0.16]) and were more likely to keep children separated from poultry (∆ = 0.09, 95% CI [0.03-0.15]) than in the control group. No differences were found for other hygiene practices, child morbidity symptoms or anthropometry indicators. Integrating livestock WASH interventions alongside poultry and nutrition interventions can increase knowledge of livestock-related risks and improve livestock-hygiene-related practices, yet may not be sufficient to improve the morbidity and nutritional status of young children.

Mobilising evidence, data, and resources to achieve global maternal and child undernutrition targets and the Sustainable Development Goals: an agenda for action.

As the world counts down to the 2025 World Health Assembly nutrition targets and the 2030 Sustainable Development Goals, millions of women, children, and adolescents worldwide remain undernourished (underweight, stunted, and deficient in micronutrients), despite evidence on effective interventions and increasing political commitment to, and financial investment in, nutrition. The COVID-19 pandemic has crippled health systems, exacerbated household food insecurity, and reversed economic growth, which together could set back improvements in undernutrition across low-income and middle-income countries. This paper highlights how the evidence base for nutrition, health, food systems, social protection, and water, sanitation, and hygiene interventions has evolved since the 2013 Lancet Series on maternal and child nutrition and identifies the priority actions needed to regain and accelerate progress within the next decade. Policies and interventions targeting the first 1000 days of life, including some newly identified since 2013, require renewed commitment, implementation research, and increased funding from both domestic and global actors. A new body of evidence from national and state-level success stories in stunting reduction reinforces the crucial importance of multisectoral actions to address the underlying determinants of undernutrition and identifies key features of enabling political environments. To support these actions, well-resourced nutrition data and information systems are essential. The paper concludes with a call to action for the 2021 Nutrition for Growth Summit to unite global and national nutrition stakeholders around common priorities to tackle a large, unfinished undernutrition agenda-now amplified by the COVID-19 crisis.

Unique and interactive associations of proactive and reactive aggression with cortisol secretion.

The association between aggressive behaviors and diurnal cortisol levels has been debated over the past two decades, as some studies found a negative link between the two, whereas others reported no or a positive association. One possible explanation for these contradictory results is that past studies failed to distinguish between proactive (PROA) and reactive (REA) aggression. The present study examined the unique and joint associations of PROA and REA with three diurnal cortisol indicators: awakening levels, awakening response, and diurnal change. Participants were 542 youths (55.4% girls) followed longitudinally. Teachers evaluated aggressive behaviors when participants were in Grades 4 and 6. In Grade 8, participants provided four saliva samples (i.e., awakening, 30 min thereafter, late afternoon, and bedtime) on four collection days. Controlling for several confounders, multilevel regression analyses revealed an inverse relation between PROA and the CAR in boys who displayed lower or moderate levels of REA, but not in those who exhibited higher levels of REA. No associations emerged with other cortisol indicators. These results are consistent with reports of lower physiological activity in individuals with PROA and underscore the confounding influence of REA in the association between the CAR and proactive aggression.

Double-duty actions: seizing programme and policy opportunities to address malnutrition in all its forms.

Actions to address different forms of malnutrition are typically managed by separate communities, policies, programmes, governance structures, and funding streams. By contrast, double-duty actions, which aim to simultaneously tackle both undernutrition and problems of overweight, obesity, and diet-related non-communicable diseases (DR-NCDs) have been proposed as a way to effectively address malnutrition in all its forms in a more holisitic way. This Series paper identifies ten double-duty actions that have strong potential to reduce the risk of both undernutrition, obesity, and DR-NCDs. It does so by summarising evidence on common drivers of different forms of malnutrition; documenting examples of unintended harm caused by some undernutrition-focused programmes on obesity and DR-NCDs; and highlighting examples of double-duty actions to tackle multiple forms of malnutrition. We find that undernutrition, obesity, and DR-NCDs are intrinsically linked through early-life nutrition, diet diversity, food environments, and socioeconomic factors. Some evidence shows that programmes focused on undernutrition have raised risks of poor quality diets, obesity, and DR-NCDs, especially in countries undergoing a rapid nutrition transition. This Series paper builds on this evidence to develop a framework to guide the design of double-duty approaches and strategies, and defines the first steps needed to deliver them. With a clear package of double-duty actions now identified, there is an urgent need to move forward with double-duty actions to address malnutrition in all its forms.

Social Assistance Programs and Birth Outcomes: A Systematic Review and Assessment of Nutrition and Health Pathways.

BACKGROUND: Poor birth outcomes are an important global public health problem. Social assistance programs that provide cash or in-kind transfers, such as food or vouchers, hold potential to improve birth outcomes but the evidence on their effectiveness has not been reviewed. OBJECTIVES: We systematically reviewed studies that used experimental or quasi-experimental methods to evaluate the impacts of social assistance programs on outcomes in low- and middle-income countries. METHODS: The Grading of Recommendations, Assessment, Development and Evaluations (GRADE) system was used to assess the certainty of the evidence for birth weight and neonatal mortality (most common outcomes reported). We summarized the evidence on hypothesized nutrition and health pathways of impact. RESULTS: We included 6 evaluations of 4 different cash transfer programs and 1 evaluation of a community-based participatory learning and action program that provided food and cash transfers. The 4 studies that assessed birth weight impacts found significant (P < 0.05) effects ranging from 31 to 578 g. Out of 3 studies that assessed neonatal mortality impacts, 2 found significant effects ranging from 0.6 to 3.1 deaths/1000 live births. The certainty of the evidence for both outcomes was rated as very low due to several methodological limitations. In terms of potential pathways, some studies documented positive effects on maternal diet, antenatal care (ANC) utilization, and delivery in a health facility. CONCLUSIONS: Better-designed evaluations are needed to strengthen the evidence base on these programs. Evaluation studies should elucidate underlying mechanisms of impact by including outcomes related to maternal diet, ANC seeking, use of skilled delivery, and women's empowerment in nutrition and health domains. Studies should also assess potential unintended negative consequences of social assistance, such as reduced birth spacing and excess pregnancy weight gain.

Tubaramure, a Food-Assisted Integrated Health and Nutrition Program, Reduces Child Wasting in Burundi: A Cluster-Randomized Controlled Intervention Trial.

BACKGROUND: Little is known about the impact of food-assisted maternal and child health programs (FA-MCHN) on child wasting. OBJECTIVES: We assessed the impact of Tubaramure, a FA-MCHN program in Burundi, on child (0 to 24 months) wasting and the differential impacts by socio-economic characteristics and age. The program targeted women and their children during the first 1000 days and included 1) food rations, 2) strengthening and promotion of use of health services, and 3) behavior change communication (BCC). METHODS: We conducted a 4-arm, cluster-randomized, controlled trial (2010-2012). Clusters were defined as "collines" (communities). Impact was estimated using repeated cross-sectional data (n = ∼2620 children in each round). Treatment arms received household and individual (mother or child in the first 1000 days) food rations (corn-soy blend and micronutrient-fortified vegetable oil) from pregnancy to 24 months (T24 arm), from pregnancy to 18 months (T18), or from birth to 24 months (TNFP). All beneficiaries received the same BCC for the first 1000 days. The control arm received no rations or BCC. RESULTS: Wasting (weight-for-length Z-score <2 SD) increased from baseline to follow-up in the control group (from 6.5% to 8%), but Tubaramure had a significant (P < 0.05) protective effect on wasting [treatment arms combined, -3.3 percentage points (pp); T18, -4.5 pp] and on the weight-for-length z-score (treatment arms combined, +0.15; T24, +0.20; T18, +0.17). The effects were limited to children whose mother and household head had no education, and who lived in the poorest households. The largest effect was found in children 6 to 12 months of age: the group with the highest wasting prevalence. CONCLUSIONS: FA-MCHN programs in highly food-insecure regions can protect the most disadvantaged children from wasting. These findings are particularly relevant in the context of the economic crisis due to the coronavirus disease 2019 pandemic, which is expected to dramatically increase child wasting.

Standard Minimum Dietary Diversity Indicators for Women or Infants and Young Children Are Good Predictors of Adequate Micronutrient Intakes in 24-59-Month-Old Children and Their Nonpregnant Nonbreastfeeding Mothers in Rural Burkina Faso.

BACKGROUND: Simple proxy indicators are needed to assess and monitor micronutrient intake adequacy of vulnerable populations. Standard dichotomous indicators exist for nonpregnant women of reproductive age and 6-23-mo-old children in low-income countries, but not for 24-59-mo-old children or pregnant or breastfeeding women. OBJECTIVES: This study aimed to evaluate the performance of 2 standard food group scores (FGSs) and related dichotomous indicators to predict micronutrient adequacy of the diet of rural Burkinabe 24-59-mo-old children and women of reproductive age by physiological status. METHODS: A 24-h recall survey was conducted at dry season among 1066 pairs of children and caregivers. Micronutrient adequacy was evaluated by the mean probability of adequacy (MPA) of intake over 11 micronutrients. Proxy indicators were FGS-10 [10 food groups based on the FAO/FHI360 minimum dietary diversity for women (MDD-W) guidelines] and related MDD-W (FGS-10 ≥5); and FGS-7 [7 groups based on the WHO infant and young child (IYC) feeding MDD guidelines] and related MDD-IYC (FGS-7 ≥4). RESULTS: FGS-10 and FGS-7 were similar across children and women (∼3 groups). FGS-10 performed better than FGS-7 to predict MPA in children (Spearman rank correlation = 0.59 compared with 0.50) and women of all 3 physiological statuses (Spearman rank correlation = 0.53-0.55 compared with 0.42-0.52). MDD-W and MDD-IYC performed well in predicting MPA >0.75 in children and MPA >0.6 in nonpregnant nonbreastfeeding (NPNB) women, but a 4-group cutoff for FGS-10 allowed a better balance between sensitivity, specificity, and proportion of correct classification. MPA levels for pregnant and breastfeeding women were too low to assess best cutoff points. CONCLUSIONS: MDD-IYC or an adapted MDD-W (FGS-10 ≥4 instead of FGS-10 ≥5) can be extended to 24-59-mo-old children and NPNB women in similar-diet settings. The inadequacy of micronutrient intakes in pregnant and breastfeeding women warrants urgent action. Micronutrient adequacy predictors should be validated in populations where a higher proportion of these women do meet dietary requirements.

Tubaramure, a Food-Assisted Maternal and Child Health and Nutrition Program in Burundi, Increased Household Food Security and Energy and Micronutrient Consumption, and Maternal and Child Dietary Diversity: A Cluster-Randomized Controlled Trial.

BACKGROUND: Food-assisted maternal and child health and nutrition programs are a widely used approach to address undernutrition. Little is known about the effects of these programs' combined household and individual food rations on household and individual food consumption. Tubaramure in Burundi targeted women and children during the first 1000 d of life, and included: 1) food rations (corn-soy blend and micronutrient-fortified vegetable oil); 2) health services strengthening and promotion of their use; and 3) behavior change communication on nutrition, hygiene, and health practices. OBJECTIVES: The objectives were: 1) to assess Tubaramure's impact on household food consumption and food security, maternal dietary diversity, and infant and young child feeding practices; 2) to explore the role of the food rations; and 3) assess 6-8 mo impacts around 8 mo after the end of the program. METHODS: We used a 4-arm cluster-randomized controlled repeated cross-sectional design (11,906 observations). The treatment arms received the same food ration but differed in the ration timing and duration: 1) the first 1000 d; 2) from pregnancy through 17.9 mo of age; or 3) from birth through 23.9 mo of age. RESULTS: Tubaramure significantly (P < 0.05) improved the percentage of food secure households [from 4.5 to 7.3 percentage points (pp)], and increased household energy consumption (from 17% to 20%) and micronutrient consumption. The program had a positive effect on maternal dietary diversity (+0.4 food groups, P < 0.05) and increased the proportion of children aged 6-23.9 mo consuming ≥4 food groups (from 8.0 to 9.6 pp, P < 0.05). The effects on many outcomes were attributable to the food rations. Postprogram effects (P < 0.05) were found on household food security, maternal dietary diversity, and younger sibling's complementary feeding practices. CONCLUSIONS: Programs such as Tubaramure have the potential to improve food security and household and individual energy and micronutrient consumption in severely resource-constrained populations, as seen in rural Burundi. This trial was registered at clinicaltrials.gov as NCT01072279.

Randomized controlled trials of multi-sectoral programs: Lessons from development research.

Development is a multi-faceted process; achieving development goals thus requires a multi-sectoral approach. For over two decades, our research group of economists and nutritionists has designed and implemented randomized trials to assess the effectiveness of multisectoral programs in improving nutrition, food security, and other measures of well-being, largely at the request of developing country governments, development partners, and non-governmental organizations. Our approach addresses three perceived pitfalls of RCTs: the "black box" nature of RCTs, limited external validity, and challenges in translation of results to impacts at scale. We address these concerns by identifying and assessing programmatic pathways to impact with quantitative and qualitative methods; studying similar programs implemented by different organizations across various settings; and working closely with implementing partners in the design, research, and dissemination processes to inform adaptation and scale-up of programs and policies.

Using structural equation modelling to understand the contributors to anaemia among young Burkinabe children.

Anaemia is a persistent problem among young Burkinabe children, yet population-specific information on its determinants is scant. We used baseline data from an evaluation of Helen Keller International's Enhanced Homestead Food Production Program (n=1210 children) to quantify household-, mother-, and child-level factors associated with anaemia in Burkinabe children aged 6-12 months. We used structural equation modelling to assess a theoretical model, which tested four categories of factors: (a) household food security and dietary diversity, (b) household sanitation and hygiene (latrine and poultry access and bednet ownership), (c) maternal factors (anaemia, stress, cleanliness, and health, hygiene and feeding knowledge and practices), and (d) child nutrition and health (iron deficiency (ID), retinol binding protein (RBP), malaria, and inflammation). The model also included household socio-economic status, size, and polygamy; maternal age and education; and child age and sex. Results showed that ID, malaria, and inflammation were the primary direct determinants of anaemia, contributing 15%, 10%, and 10%, respectively. Maternal knowledge directly explained improved child feeding practices and household bednet ownership. Household dietary diversity directly explained 18% of child feeding practices. Additionally, RBP, child age and sex, and maternal anaemia directly predicted child haemoglobin. Our findings suggest that program effectiveness could be increased by addressing the multiple, context-specific contributors of child anaemia. For young Burkinabe children, anaemia control programs that include interventions to reduce ID, malaria, and inflammation should be tested. Other potential intervention entry points suggested by our model include improving maternal knowledge of optimal health, hygiene, and nutrition practices and household dietary diversity.

The cost of improving nutritional outcomes through food-assisted maternal and child health and nutrition programmes in Burundi and Guatemala.

Evidence on the cost-effectiveness of multisectoral maternal and child health and nutrition programmes is scarce. We conducted a prospective costing study of two food-assisted maternal and child health and nutrition programmes targeted to pregnant women and children during the first 1,000 days (pregnancy to 2 years). Each was paired with a cluster-randomized controlled trial to evaluate impact and compare the optimal quantity and composition of food rations (Guatemala, five treatment arms) and their optimal timing and duration (Burundi, three treatment arms). We calculated the total and per beneficiary cost, conducted cost consequence analyses, and estimated the cost savings from extending the programme for 2 years. In Guatemala, the programme model with the lowest cost per percentage point reduction in stunting provided the full-size family ration with an individual ration of corn-soy blend or micronutrient powder. Reducing family ration size lowered costs but failed to reduce stunting. In Burundi, providing food assistance for the full 1,000 days led to the lowest cost per percentage point reduction in stunting. Reducing the duration of ration eligibility reduced per beneficiary costs but was less effective. A 2-year extension could have saved 11% per beneficiary in Guatemala and 18% in Burundi. We found that investments in multisectoral nutrition programmes do not scale linearly. Programmes providing smaller rations or rations for shorter durations, although less expensive per beneficiary, may not provide the necessary dose to improve (biological) outcomes. Lastly, delivering effective programmes for longer periods can generate cost savings by dispersing start-up costs and lengthening peak operating capacity.

Impact on child acute malnutrition of integrating a preventive nutrition package into facility-based screening for acute malnutrition during well-baby consultation: A cluster-randomized controlled trial in Burkina Faso.

BACKGROUND: Community management of acute malnutrition (CMAM) is a highly efficacious approach for treating acute malnutrition (AM) in children who would otherwise be at significantly increased risk of mortality. In program settings, however, CMAM's effectiveness is limited because of low screening coverage of AM, in part because of the lack of perceived benefits for caregivers. In Burkina Faso, monthly screening for AM of children <2 years of age is conducted during well-baby consultations (consultation du nourrisson sain [CNS]) at health centers. We hypothesized that the integration of a preventive package including age-appropriate behavior change communication (BCC) on nutrition, health, and hygiene practices and a monthly supply of small-quantity lipid-based nutrient supplements (SQ-LNSs) to the monthly screening would increase AM screening and treatment coverage and decrease the incidence and prevalence of AM. METHODS AND FINDINGS: We used a cluster-randomized controlled trial and allocated 16 health centers to the intervention group and 16 to a comparison group. Both groups had access to standard CMAM and CNS services; caregivers in the intervention group also received age-appropriate monthly BCC and SQ-LNS for children >6 months of age. We used two study designs: (1) a repeated cross-sectional study of children 0-17 months old (n = 2,318 and 2,317 at baseline and endline 2 years later) to assess impacts on AM screening coverage, treatment coverage, and prevalence; (2) a longitudinal study of 2,113 children enrolled soon after birth and followed up monthly for 18 months to assess impacts on AM screening coverage, treatment coverage, and incidence. Data were analyzed as intent to treat. Level of significance for primary outcomes was α = 0.016 after adjustment for multiple testing. Children's average age was 8.8 ± 4.9 months in the intervention group and 8.9 ± 5.0 months in the comparison group at baseline and, respectively, 0.66 ± 0.32 and 0.67 ± 0.33 months at enrollment in the longitudinal study. Relative to the comparison group, the intervention group had significantly higher monthly AM screening coverage (cross-sectional study: +18 percentage points [pp], 95% CI 10-26, P < 0.001; longitudinal study: +23 pp, 95% CI 17-29, P < 0.001). There were no impacts on either AM treatment coverage (cross-sectional study: +8.0 pp, 95% CI 0.09-16, P = 0.047; longitudinal study: +7.7 pp, 95% CI -1.2 to 17, P = 0.090), AM incidence (longitudinal study: incidence rate ratio = 0.98, 95% CI 0.75-1.3, P = 0.88), or AM prevalence (cross-sectional study: -0.46 pp, 95% CI -4.4 to 3.5, P = 0.82). A study limitation is the referral of AM cases (for ethical reasons) by study enumerators as part of the monthly measurement in the longitudinal study that may have attenuated the detectable impact on AM treatment coverage. CONCLUSIONS: Adding a preventive package to CMAM delivered at health facilities in Burkina Faso increased participation in monthly AM screening, thus overcoming a major impediment to CMAM effectiveness. The lack of impact on AM treatment coverage and on AM prevalence and incidence calls for research to address the remaining barriers to uptake of preventive and treatment services at the health center and to identify and test complementary approaches to bring integrated preventive and CMAM services closer to the community while ensuring high-quality implementation and service delivery. TRIAL REGISTRATION: ClinicalTrials.gov NCT02245152.

Impact on child acute malnutrition of integrating small-quantity lipid-based nutrient supplements into community-level screening for acute malnutrition: A cluster-randomized controlled trial in Mali.

BACKGROUND: Community-based management of acute malnutrition (CMAM) has been widely adopted to treat childhood acute malnutrition (AM), but its effectiveness in program settings is often limited by implementation constraints, low screening coverage, and poor treatment uptake and adherence. This study addresses the problem of low screening coverage by testing the impact of distributing small-quantity lipid-based nutrient supplements (SQ-LNSs) at monthly screenings held by community health volunteers (CHVs). Screening sessions included behavior change communication (BCC) on nutrition, health, and hygiene practices (both study arms) and SQ-LNSs (one study arm). Impact was assessed on AM screening and treatment coverage and on AM incidence and prevalence. METHODS AND FINDINGS: A two-arm cluster-randomized controlled trial in 48 health center catchment areas in the Bla and San health districts in Mali was conducted from February 2015 to April 2017. In both arms, CHVs led monthly AM screenings in children 6-23 months of age and provided BCC to caregivers. The intervention arm also received a monthly supply of SQ-LNSs to stimulate caregivers' participation and supplement children's diet. We used two study designs: i) a repeated cross-sectional study (n = approximately 2,300) with baseline and endline surveys to examine impacts on AM screening and treatment coverage and prevalence (primary study outcomes) and ii) a longitudinal study of children enrolled at 6 months of age (n = 1,132) and followed monthly for 18 months to assess impact on AM screening and treatment coverage and incidence (primary study outcomes). All analyses were done by intent to treat. The intervention significantly increased AM screening coverage (cross-sectional study: +40 percentage points [pp], 95% confidence interval [CI]: 32, 49, p < 0.001; longitudinal study: +28 pp, 95% CI: 23, 33, p < 0.001). No impact on treatment coverage or AM prevalence was found. Children in the intervention arm, however, were 29% (95% CI: 8, 46; p = 0.017) less likely to develop a first AM episode (incidence) and, compared to children in comparison arm, their overall risk of AM (longitudinal prevalence) was 30% (95% CI: 12, 44; p = 0.002) lower. The intervention lowered CMAM enrollment by 10 pp (95% CI: 1.9, 18; p = 0.016), an unintended negative impact likely due to CHVs handing out preventive SQ-LNSs to caregivers of AM children instead of referring them to the CMAM program. Study limitations were i) the referral of AM cases by our research team (for ethical reasons) during monthly measurements in the longitudinal study might have interfered with usual CMAM activities and ii) the outcomes presented by child age also reflect seasonal variations because of the closed cohort design. CONCLUSIONS: Incorporating SQ-LNSs into monthly community-level AM screenings and BCC sessions was highly effective at improving screening coverage and reducing AM incidence, but it did not improve AM prevalence or treatment coverage. Future evaluation and implementation research on CMAM should carefully assess and tackle the remaining barriers that prevent AM cases from being correctly diagnosed, referred, and adequately treated. TRIAL REGISTRATION: ClinicalTrials.gov NCT02323815.

A Multisectoral Food-Assisted Maternal and Child Health and Nutrition Program Targeted to Women and Children in the First 1000 Days Increases Attainment of Language and Motor Milestones among Young Burundian Children.

BACKGROUND: Child development is affected by multiple factors throughout pregnancy and childhood. Multisectoral programs addressing these factors may improve children's development. OBJECTIVE: We evaluated the impact of a food-assisted multisectoral nutrition program (Tubaramure) on children's (4-41.9 mo) motor and language development. Tubaramure was targeted to Burundian women and children in the first 1000 d and provided micronutrient-fortified food rations; nutrition, health, and hygiene behavior change communication; and health system-strengthening activities. METHODS: Program impact was assessed using a cluster-randomized controlled trial with repeated cross-sections: 2010 (baseline, children 4-41.9 mo), 2012 (follow-up during implementation, children 4-23.9 mo), and 2014 (follow-up postimplementation, children 24-41.9 mo). Sixty villages were randomly assigned to 4 groups with varying timing and duration of food rations: pregnancy-24 mo; pregnancy-18 mo; 0-24 mo; and control, no direct Tubaramure benefits. Treatment groups were pooled and compared with control using difference-in-difference estimates. We examined impact pathways by assessing program impacts on intermediary variables and their associations with development outcomes. RESULTS: At first follow-up, Tubaramure positively affected language (0.4 milestones, P < 0.05) but not motor development among children aged 4-23.9 mo. Among the 12-23.9 mo age subgroup, the program positively affected language (0.7 milestones, P < 0.01) and motor (0.6 milestones, P = 0.08) development. At second follow-up, among children aged 24-41.9 mo, Tubaramure marginally affected motor development (0.4 milestones, P = 0.09). In age subgroup analyses, program impacts were limited to children aged 24-29.9 mo [0.4 motor (P = 0.09) and 1.0 language (P < 0.01) milestones]. Pathway analyses revealed significant positive impacts on diet, health, and nutritional indicators of children aged 12-23.9 mo and health and nutritional indicators of children aged 24-29.9 mo, supporting the plausibility of program impacts on child development. CONCLUSIONS: Tubaramure had small positive impacts on children's motor and language development through multiple pathways, demonstrating the role multisectoral nutrition programs can play in improving children's development. This trial was registered at clinicaltrials.gov as NCT01072279.

PROCOMIDA, a Food-Assisted Maternal and Child Health and Nutrition Program, Contributes to Postpartum Weight Retention in Guatemala: A Cluster-Randomized Controlled Intervention Trial.

BACKGROUND: Food-assisted maternal and child health and nutrition (FA-MCHN) programs are widely used to reduce household food insecurity and maternal and child undernutrition in low- and middle-income countries. These programs, however, may unintentionally lead to excessive energy intake and unhealthy weight gain, especially in food-secure populations. OBJECTIVE: We evaluated the impact of an FA-MCHN program implemented in Guatemala on maternal weight from pregnancy to 24 mo postpartum. The program was earlier shown to reduce stunting. METHODS: We used a longitudinal, cluster-randomized controlled trial with arms varying in family ration size [full (FFR), reduced (RFR), none (NFR)] and individual maternal ration type [corn-soy blend (CSB), lipid-based nutrient supplement (LNS), micronutrient powder (MNP)]: A: FFR + CSB; B: RFR + CSB; C: NFR + CSB; D: FFR + LNS; E: FFR + MNP; F: control. Weight was measured during pregnancy and at 1, 4, 6, 9, 12, 18, and 24 mo postpartum. We used linear mixed models controlling for pregnancy weight with random cluster and mother effects. Data on 3535 women were analyzed. RESULTS: Significant (P < 0.05) or marginally significant (P < 0.10) effects of 0.50-0.65 kg were found at all time points (except 9 mo) in arm A. Similar-sized effects were found in arms B (1, 4, 6, and 12 mo) and C (1 and 12 mo). Marginally significant effects (0.51-0.66 kg) were found in arm D (1, 6, 9, and 12 mo); in arm E, marginally significant effects (0.48-0.75 kg) were found from 6 to 24 mo. CONCLUSIONS: The effect on maternal postpartum weight is of concern because of the high existing prevalence of overweight. Programs need to include "double-duty" objectives and actions, to ensure that addressing child undernutrition does not exacerbate the problem of unhealthy weight gain. This trial was registered at clinicaltrials.gov as NCT01072279.

Behavior Change Interventions Delivered through Interpersonal Communication, Agricultural Activities, Community Mobilization, and Mass Media Increase Complementary Feeding Practices and Reduce Child Stunting in Ethiopia.

BACKGROUND: Appropriate infant and young child feeding practices are critical for optimal child growth and development, but in Ethiopia, complementary feeding (CF) practices are very poor. Alive & Thrive (A&T) provided intensive behavior change interventions through 4 platforms: interpersonal communication (IPC), nutrition-sensitive agricultural activities (AG), community mobilization (CM), and mass media (MM). OBJECTIVES: The aim of this study was to evaluate the impact of A&T intensive compared with nonintensive interventions (standard nutrition counseling and agricultural extension service and less intensive CM and MM) on CF practices and knowledge and child anthropometric outcomes. METHODS: We used a cluster-randomized evaluation design with cross-sectional surveys among households with children aged 6-23.9 mo [n = 2646 at baseline (2015) and n = 2720 at endline (2017)]. We derived difference-in-difference impact estimates (DDEs) and conducted dose-response and path analyses to document plausibility of impacts. RESULTS: At endline, exposure to IPC was 17.8-32.3%, exposure to AG was 22.7-36.0%, exposure to CM was 18.6-54.3%, and exposure to MM was 35.4% in the intensive group. Minimum dietary diversity and minimum acceptable diet increased significantly in the intensive group but remained low at endline (24.9% and 18.2%, respectively). Significant differential declines in stunting prevalence were observed (DDE: -5.6 percentage points; P < 0.05) in children aged 6-23.9 mo, decreasing from 36.3% to 22.8% in the intensive group. Dose-response analyses showed higher odds of minimum dietary diversity (OR: 3.3; 95% CI: 2.2, 4.8) and minimum meal frequency (OR: 1.9; 95% CI: 1.4, 2.6) and higher height-for-age z score (HAZ) (ß: 0.24; 95% CI: 0.04, 0.4) among women exposed to 3 or 4 platforms. Path analyses showed a strong relation between AG and egg consumption, which led to increased child dietary diversity and HAZ. CONCLUSIONS: Delivery of social and behavior change interventions using multiple platforms was feasible and effective, resulting in improvements in CF practices and child stunting within a 2-y period. There is a need for continued efforts, however, to expand intervention coverage and to improve CF practices in Ethiopia. This trial was registered at clinicaltrials.gov as NCT02775552.

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

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