Prevalence of overweight and obesity, dietary behaviors, and physical activities among sixth graders: a cross-sectional study in Ho Chi Minh City, Vietnam.

The prevalence of overweight and obesity among adolescents has been increasing worldwide and is a significant public health challenge. Obesity is linked to several non-communicable diseases. This study aimed to determine the prevalence of overweight and obesity based on three growth references and described physical activities and dietary patterns among sixth graders in Ho Chi Minh City (HCMC). From 2018 to 2020, a cross-sectional study was conducted on 1375 students from 16 junior high schools in HCMC. We applied Probability Proportional to Size sampling to select schools. Anthropometric measurements, pubertal status assessment, and diet and physical activity data were collected through Food Frequency and Physical Activity Questionnaires. The study revealed a high prevalence of overweight and obesity among grade 6 students, with ∼45%-56% of students classified as overweight or obese using various growth references. Moreover, most students did not meet the World Health Organization's physical activity and sedentary behavior recommendations. Most students spent <60 min/day on moderate to vigorous physical activity, and over 70% spent at least 120 min/day on sedentary activities during weekdays and weekends. The diet of the students was also imbalanced, with high intakes of protein, lipids, and carbohydrates and low consumption of fruits and vegetables. Nutritionists and policymakers should inform and encourage opportunities for healthier food and more daily activity for children, starting before the sixth-grade, so they can learn how to make healthier choices and change their behavior before they reach adolescence.

Caregiver perceptions of complementary feeding in rural and urban Indonesia: A qualitative comparative study.

OBJECTIVE: To explore caregivers' perspectives on complementary feeding in rural and urban areas of Central Java, Indonesia. DESIGN: A qualitative comparative study using in-depth interviews. We applied thematic analysis to identify themes and subthemes and presented representative quotes. SETTING: Rural and urban villages in Central Java Province, Indonesia. PARTICIPANTS: 46 mothers and grandmothers of 6- to 23-month-old children. FINDINGS: We identified five themes: 1) timing of food introduction, 2) types of complementary foods, 3) meal preparations, 4) complementary food benefits, and 5) expectations toward complementary foods. While caregivers in urban areas had more favourable perceptions of complementary feeding, some misperceptions existed regarding complementary feeding in both areas. These misconceptions included the age of complementary food introduction, the delay in introducing animal-source foods, and the emphasis on any food the child preferred as long as they ate rather than on healthy food choices. KEY CONCLUSIONS: There were similarities and differences in complementary feeding perspectives between caregivers in rural and urban areas. Therefore, policymakers and public health workers should design interventions to enhance complementary feeding practices by addressing the contextual issues in specific settings.

The Effectiveness of Nutritional Interventions Implemented through Lady Health Workers on the Reduction of Stunting in Children under 5 in Pakistan: The Difference-in-Difference Analysis.

In Pakistan, the 2018 National Nutrition Survey reported that 40% of children under five years old were stunted. This study assessed the effectiveness of nutritional supplementation in reducing stunting among children under five years old in two rural districts in Sindh, Pakistan. This was a mixed-method quasi-experimental study comprising intervention and control populations, with 3397 and 3277 children under five years old participating in the baseline and end-line surveys, respectively. The study areas were similar in terms of demographic and economic circumstances. In the intervention group, pregnant and lactating women (first six months post-partum) received wheat soy blend, children 6-23 months old received Wawamum (lipid-based supplement), and children 24-59 months old received micronutrient powders, all through lady health workers. This was underpinned by nutrition behaviour change communication for appropriate complementary feeding practices and hygiene promotion targeted at primary caregivers. The control group received no intervention. The impact was assessed using the difference-in-difference analysis with kernel propensity score matching to adjust the differences among the control and intervention populations. The overall DID analysis indicated that the intervention did not significantly reduce the prevalence of stunting (under 5 years) [DID = -5.1, p = 0.079]. The adjusted DID indicated a significant decrease of 13% [DID = -13.0, p = 0.001] in the number of stunted children 24-59 months of age at the endline survey. A significant reduction in underweight among children 24-59 months old was also observed (DID = -9.4%, p = 0.014). In conclusion, this evidence further establishes that nutrient uptake through an intervention for a short duration cannot effectively reduce stunting. It requires continuous nutritional supplementation for mothers during the pregnancy and an initial six months of lactation and then nutritional supplementation for children 6-59 months of age underpinned by effective behaviour change communication targeting mothers and other caregivers for improving complementary feeding practices and hygiene promotion.

Women's participation in household decision-making: Qualitative findings from the Shonjibon Trial in rural Bangladesh.

A key element of women's empowerment is the ability to participate in household decision-making. This study presents the qualitative results from the Shonjibon Cash and Counselling Trial baseline process evaluation with the aim of exploring the status of women's decision-making at the trial's outset and to facilitate the exploration of any changes in women's empowerment over the course of the trial. Between January and March 2021, we conducted forty-one in-depth interviews with pregnant women in rural Bangladesh. The research team translated, transcribed, coded, and discussed the interviews. We used thematic analysis to examine women's experience and perceptions on household decision-making. The key findings that emerged; women jointly participated in financial decision-making with their husbands; men made the final decision regarding seeking healthcare, and women solely made choices regarding infant and young child feeding. Our findings revealed that women felt that they needed to discuss their plans to go outside the house with their husbands, many perceived a lack of importance in the community towards women's participation in decision-making. This study documents current contextual information on the status of women's involvement in household decision-making and intrahousehold power dynamics at the start of the Shonjibon Cash and Counselling Trial.

Mother's Dietary Diversity and Underweight among Under-five Rural Children in Three Major Agro-climatic Zones, Myanmar.

Background: Children's growth is essential to nutritional status and population health. In 2015, 18.9% of under-five children in Myanmar were underweight, and only 25% of 6-23-month-old children had the minimum dietary diversity (MDD). Objectives: We conducted this study to assess the association between mother's dietary diversity score (DDS) and underweight among under-five children. Materials and Methods: This study analyzed data from the "Livelihood and Food Security Survey," a cross-sectional study conducted in 2016 in rural areas in Chin State, Magway, and Ayeyarwady regions. It included 2029 under-five children and used underweight as an outcome variable. We calculated DDSs for mothers of under-five children using the MDD-women methodology. The prevalence of underweight and MDD were estimated. A multivariable binary logistic regression analysis estimated odds ratios and 95% confidence intervals (CIs). Results: The overall prevalence of underweight was 26.3% (95% CI: 23.4, 29.3), and that of the mother with a MDD score was 29.2% (95% CI: 26.0, 32.8). Multivariable binary logistic regression analysis showed that the prevalence of underweight in children was higher if maternal MDD was not met (adjusted odds ratio = 1.41; 95% CI: 1.05, 1.89). Conclusions: The children's age, types of toilets, and region were independent predictors of being underweight. Underweight among under-five children and diverse food consumption among their mothers are critical public health challenges in rural Myanmar that require urgent action. Nutrition education for rural communities should focus on feeding children with locally available diverse foods.

Factors influencing breastfeeding continuation and formula feeding beyond six months in rural and urban households in Indonesia: a qualitative investigation.

BACKGROUND: Global and Indonesian guidelines suggest that breastfeeding should continue for at least the first two years of life. While many studies have focused on six-month exclusive breastfeeding practices, little is known about why mothers do not sustain breastfeeding beyond this period. This qualitative study aimed to explore factors influencing breastfeeding continuation and formula feeding beyond six months, regardless of any additional food consumed, focusing on Indonesia's rural and urban areas. METHODS: We collected the data through 46 in-depth interviews in Pati District and Surakarta City, Central Java, Indonesia. Participants were mothers, grandmothers, health care practitioners, and village kader (frontline female health workers). We used thematic analysis combining deductive and inductive techniques for analysing the data. RESULTS: Rural mothers practised breastfeeding and intended to breastfeed for a longer duration than urban mothers. Maternal attitude towards breastfeeding, breastfeeding knowledge, previous experiences, and other breastfeeding strategies (e.g., enhancing maternal dietary quality) positively influenced breastfeeding sustainability. In the urban setting, mothers encountered several breastfeeding barriers, such as perceived breast milk insufficiency and child hunger and satiety, child biting, and breastfeeding refusal, causing them to provide formula milk as a breast milk substitute or supplement. In addition, families, communities, health practitioners, and employment influenced maternal decisions in breastfeeding continuation and formula-feeding practices. CONCLUSIONS: Optimal breastfeeding practices up to two years of age are determined by the individual and setting (i.e., community, healthcare, employment) factors. Providing breastfeeding education covering practical breastfeeding guidance will encourage mothers to breastfeed for longer. Such interventions should involve families, communities, health workers, and the work environment as a breastfeeding support system. Policymakers should develop, enforce, and monitor the implementation of breastfeeding policies to protect, promote, and support breastfeeding in households, communities, health systems, and work settings.

Socio-economic and agricultural factors associated with stunting of under 5-year children: findings from surveys in mountains, dry zone and delta regions of rural Myanmar (2016-2017).

OBJECTIVE: The study's objective was to investigate multiple underlying social, economic and agricultural determinants of stunting among under-five children in three distinct ecological areas in rural Myanmar. DESIGN: Repeated cross-sectional surveys in three states of Myanmar. SETTING: Rural households in Chin (mountainous), Magway (plains) and Ayeyarwady (delta). PARTICIPANTS: From two purposively selected adjacent townships in each state, we randomly selected twenty villages and, in each village, thirty households with under-five children. Households in the first survey in 2016 were revisited in late 2017 to capture seasonal variations. RESULTS: Stunting increased from 40·4 % to 42·0 %, with the highest stunting prevalence in Chin state (62·4%). Univariate Poisson regression showed factors contributing to child stunting varied across the regions. Adjusted Poisson regression models showed that child's age and short maternal stature (aRR = 1·14 for Chin, aRR = 1·89 for Magway and aRR = 1·86 for Ayeyarwady) were consistently associated with child stunting across three areas. For Chin, village-level indicators such as crop consumption (aRR = 1·18), crop diversity (aRR = 0·82) and land ownership (aRR = 0·89) were significantly associated with stunting. In Magway, the number of household members (aRR = 1·92), wealth status (aRR = 0·46), food security status (aRR = 1·14), land ownership (aRR = 0·85) and in Ayeyarwady, women's decision-making (aRR = 0·67) and indicators related to hygiene (aRR = 1·13) and sanitation (aRR = 1·45) were associated with stunting. CONCLUSIONS: Area-specific factors were associated with stunting. Maternal short stature and child age were consistent determinants of stunting. A multi-sectoral local approach, including improvements in transport, is needed to address the intergenerational malnutrition problem.

Tailored text messages to improve breastfeeding practices in Yangon, Myanmar: the M528 individually randomized controlled trial.

BACKGROUND: Text messages are a feasible delivery channel for breastfeeding promotion, but only a few articles have examined their effectiveness. OBJECTIVE: To evaluate the impact of mobile phone text messages on breastfeeding practices. DESIGN: We implemented a 2-arm, parallel, individually randomized controlled trial with 353 pregnant participants at the Central Women's Hospital, Yangon. The intervention group (n = 179) received breastfeeding-promotion text messages, and the control group (n = 174) received other maternal and child health care messages. The primary outcome was the exclusive breastfeeding rate at 1-6 mo postpartum. Secondary outcomes were other breastfeeding indicators, breastfeeding self-efficacy, and child morbidity. Using the intention-to-treat approach, the available outcome data were analyzed with generalized estimation equation Poisson regression models to estimate RR and 95% CIs, adjusted for within-person correlation and time, and tested for treatment group-by-time interactions. RESULTS: Exclusive breastfeeding prevalence was significantly higher in the intervention than in the control group for the 6 follow-up visits combined (RR: 1.48; 95%CI: 1.35, 1.63; P < 0.001) and at each monthly follow-up visit. At 6 mo, exclusive breastfeeding was 43.4% in the intervention compared with 15.3% in the control group (RR: 2.74; 95%CI: 1.79, 4.19; P < 0.001). Also, at 6 mo, the intervention increased current breastfeeding (RR: 1.17; 95%CI: 1.07, 1.26; P < 0.001) and reduced bottle feeding (RR: 0.30; 95%CI: 0.17, 0.54; P < 0.001). Exclusive breastfeeding was progressively higher in the intervention group than in the control group at each follow-up (P for interaction < 0.001) and similarly for current breastfeeding. The intervention increased the mean breastfeeding self-efficacy score (adjusted mean difference 4.0; 95%CI: 1.36, 6.64; P = 0.030). Over the 6-month follow-up, the intervention significantly reduced diarrhea risk by 55% (RR: 0.45; 95%CI: 0.24, 0.82; P < 0.009). CONCLUSIONS: Regular, targeted text messages delivered to urban pregnant women and mothers via mobile phones significantly improve breastfeeding practices and reduce infant morbidity during the first 6 mo of life. TRIAL REGISTRATION: Australian New Zealand Clinical Trials Registry ACTRN12615000063516; https://anzctr.org.au/Trial/Registration/TrialReview.aspx?id=367704.

Effects of antenatal micronutrient supplementation regimens on adolescent emotional and behavioral problems: A 14-year follow-up of a double-blind, cluster-randomized controlled trial.

BACKGROUND & AIMS: Antenatal multiple micronutrient supplementation has been shown to have beneficial effects on birth outcomes and may improve child development. However, whether there is an effect of antenatal micronutrient supplementation strategies on offspring socioemotional outcomes remains unknown. We aimed to examine the effect of antenatal folic acid (FA), iron-folic acid (IFA), and multiple micronutrient (MMN) supplementation on adolescent emotional and behavioral outcomes. METHODS: We conducted a double-blind, cluster-randomized trial of antenatal micronutrient supplementation in rural western China between 2002 and 2006. Pregnant females were randomized by village to receive either daily (i) 400 µg FA, (ii) IFA containing 60 mg iron and 400 µg FA or (iii) MMN supplementation containing 30 mg iron, 400 µg FA plus 13 additional vitamins and minerals. A 14-year follow-up of their offspring was conducted in 2016. Adolescents were administered the locally adapted Youth Self-Report-2001 (YSR-2001) which produced internalizing, externalizing, and total behavior problem scores. We applied generalized estimating equations to assess the effect of the randomized regimens on YSR-2001 scores and explored the potential effect modification by household wealth and initial timing and duration of supplementation. RESULTS: A total of 1920 adolescents were included in the analysis, 1130 (58.9%) were male, and the mean (SD) age was 11.8 (0.78) years. Adolescents in IFA group had lower total (mean difference (MD): -2.89; 95% CI -5.73, -0.04) and externalizing (MD: -0.97; 95% CI -1.79, -0.15) problem scores as compared to those in FA group. There was no effect of MMN on behavior problem scores as compared to IFA and FA alone. Although, in effect modification analyses, MMN appeared to have greater beneficial effects in wealthier households than IFA and FA alone. CONCLUSIONS: Iron supplementation during pregnancy reduced adolescent emotional and behavioral problem scores which provides additional support for expanding coverage of iron-containing prenatal supplements in resource-limited settings. TRIAL REGISTRATION: isrctn. org Identifier: ISRCTN08850194.

Energy intakes, macronutrient intakes and the percentages of energy from macronutrients with adolescent BMI: results from a 5-year cohort study in Ho Chi Minh City, Vietnam.

BACKGROUND: Adolescence is a period of life when dietary patterns and nutrient intakes may greatly influence adult fatness. This study assesses the tracking of energy and nutrient intakes of Ho Chi Minh City adolescents over 5 years. It explores the possible relationships between energy and the percentage of energy from macronutrients with BMI. METHODS: Height, weight, time spent on physical activity, screen time and dietary intakes were collected annually between 2004 and 2009 among 752 junior high school students with a mean age of 11·87 years at baseline. The tracking was investigated using correlation coefficients and weighted kappa statistics (k) for repeated measurements. Mixed effect models were used to investigate the association between energy intakes and percentage energy from macronutrients with BMI. RESULTS: There were increases in the mean BMI annually, but greater in boys than in girls. Correlation coefficients (0·2 < r < 0·4) between participants' intakes at baseline and 5-year follow-up suggest moderate tracking. Extended kappa values were lowest for energy from carbohydrate (CHO) in both girls and boys (k = 0·18 & 0·24, respectively), and highest for protein in girls (k = 0·47) and fat in boys (k = 0·48). The multilevel models showed the following variables significantly correlated with BMI: CHO, fat, percentage of energy from CHO, fat, time spent for moderate to vigorous physical activity, screen time, age and sex. CONCLUSIONS: The poor to fair tracking observed in this cohort suggests that individual dietary patterns exhibited in the first year are unlikely to predict energy and nutrient intakes in the fifth year.

Effectiveness of peer-led programs for overweight and obesity in children: systematic review and meta-analysis.

Child health promotion has used peer-led interventions for decades, but their effectiveness for childhood obesity is unknown. This review assesses the effectiveness of peer-led interventions on child and adolescent obesity using a range of adiposity outcomes. We included studies that used a peer-led approach for delivering behavior change communications with a minimum intervention duration of four weeks. Studies needed to report results for any of the outcomes: BMI, BMI z-score or BMI percentile. The review included 14 studies of moderate to high quality from high-income countries. A meta-analysis involving 2506 children from 9 studies showed that programs were effective with a mean difference in BMI of -0.15 kg/m2 (95% confidence interval [-0.26, -0.03]), p = 0.01. Heterogeneity was low (I2 = 28%, p = 0.19) for children in the intervention group. The mean difference varied with subgroups with significantly greater effects from interventions that focused on physical activity alone or with longer duration of implementation. Sensitivity analysis showed similar significant findings to the primary meta-analysis. We found moderately strong evidence to support the advantageous effect of peer-led interventions for obesity prevention in children and adolescents. However, given the small number of studies included, and possible reporting bias, the results must be interpreted cautiously.

The Role of mHealth Interventions in Changing Gender Relations: Systematic Review of Qualitative Findings.

BACKGROUND: The rapid and widespread growth of mobile technologies in low- and middle-income countries can offer groundbreaking ways of disseminating public health interventions. However, gender-based inequalities present a challenge for women in accessing mobile technology. Research has shown that mobile health (mHealth) interventions can affect gender relations in both positive and negative ways; however, few mHealth programs use a gender-sensitive lens when designing, implementing, or analyzing programs. OBJECTIVE: This systematic review aims to identify and summarize the findings of qualitative research studies that explore the impact of mHealth interventions on gender relations as a result of participating in such initiatives in low- and middle-income countries. METHODS: We performed a systematic literature review to examine empirical evidence of changes in gender relations attributed to participation in an mHealth intervention in low- and middle-income countries. Peer-reviewed articles were included based on whether they evaluated an mHealth intervention and were published between 2013 and 2020. Articles using mHealth that solely targeted health workers, did not assess a specific intervention, used mobile technology for data collection only, or were formative or exploratory in nature were excluded. The search terms were entered into 4 key electronic databases-MEDLINE, EMBASE, PsycINFO, and Scopus-generating a comprehensive list of potentially relevant peer-reviewed articles. Thematic analysis was used to identify, analyze, and report the themes that emerged from our data. RESULTS: Of the 578 full-text articles retrieved, 14 (2.4%) were eligible for inclusion in the study. None of the articles appraised gender from the outset. The articles uncovered findings on gender relations through the course of the intervention or postprogram evaluation. Most studies took place in sub-Saharan Africa, with the remainder in South and Southeast Asia. The articles focused on maternal and child health, HIV diagnosis and treatment, and reproductive health. This review found that mHealth programs could enhance spousal communication, foster emotional support between couples, improve women's self-efficacy and autonomy in seeking health information and services, and increase their involvement in health-related decision-making. Despite the positive impacts, some mHealth interventions had an adverse effect, reinforcing the digital divide, upholding men as gatekeepers of information and sole decision-makers, and exacerbating relationship problems. CONCLUSIONS: These results suggest that given the rapid and persistent upscale of mHealth interventions in low- and middle-income settings, it is imperative to design interventions that consider their impact on power dynamics and gender relations. Future research is needed to fill the evidence gaps on gender and mHealth, acknowledging that women are not passive beneficiaries and that they need to actively participate and be empowered by mHealth interventions.

Head circumference trajectories during the first two years of life and cognitive development, emotional, and behavior problems in adolescence: a cohort study.

The associations of early-life head circumference (HC) with child neurodevelopmental and mental health among generally healthy population remain unclear. We aimed to examine the associations of early-life HC trajectories with cognitive development and emotional and behavioral problems in adolescence and to identify the HC growth-sensitive period. We conducted a prospective, community-based birth cohort study in rural western China, and 745 adolescents aged 10-14 years were followed between June and December 2016. We assessed their HC eight times during the first 2 years of life and their adolescent cognitive, emotional, and behavioral outcomes using the Wechsler Intelligence Scale for Children-IV and Youth Self-Report-2001, respectively. We applied group-based trajectory modeling to identify the HC trajectories and conditional growth to derive the HC growth-sensitive periods. We identified five distinct HC trajectories characterized as Start below average-then decrease (7.8% of the sample), Start below average-then increase (6.8%), Start average-then decrease (33%), Consistently average (38%), and Consistently above average (14%). Infants in the trajectory of consistently above average had higher cognitive scores in adolescence compared to those from suboptimal trajectories, with adjusted mean differences ranging from 2.84 to 8.99 points. The conditional gains showed that the HC growth-sensitive period was between 0 and 18 months for child cognition. We found null associations between HC measures and adolescent emotional and behavioral problem scores. CONCLUSION: Early-life HC trajectories were associated with adolescent cognitive development. HC may serve as an inexpensive screening tool to monitor child development at risk during the first 18 months, particularly in resource-limited settings. WHAT IS KNOWN: • Postnatal head circumference (HC) has been shown to be associated with cognitive development in infants who were born premature and/or fetal growth restriction, while inconsistent associations were reported among generally healthy populations, especially in low- and middle- income countries, challenging its utility in public health practices. WHAT IS NEW: • Adolescents in the HC growth trajectory of consistently above average had higher cognitive scores compared to those with other suboptimal trajectories, while null findings were observed for adolescent emotional and behavioral health. • HC may serve as an inexpensive screening tool to monitor child development at risk during the first 18 months of life, particularly in resource-limited settings.

Reducing household air pollution exposure to improve early child growth and development; a randomized control trial protocol for the "Poriborton-Extension: The CHANge trial".

BACKGROUND: Globally, household air pollution (HAP) is a leading environmental cause of morbidity and mortality. Our trial aims to assess the impact of liquefied petroleum gas (LPG) for cooking to reduce household air pollution exposure on child health outcomes, compared to usual cooking practices in Bangladesh. The primary aim is to evaluate if reduced exposure to HAP through the provision of LPG for cooking from early gestation through to age 2 improves child anthropometry, health, and neuro-cognitive developmental outcomes, compared to children exposed to emissions from usual practice. METHODS: Two-arm parallel cluster randomized controlled trial (cCRT). We will extend the intervention and follow-up of our existing "Poriborton" trial. In a subset of the original surviving participants, we will supply LPG cylinders and LPG stoves (intervention) compared to usual cooking practices and extend the follow-up to 24 months of age. The expected final sample size, for both (intervention and control) is 1854 children with follow-up to 2 years of age available for analysis. DISCUSSION: This trial will answer important research gaps related to HAP and child health and neuro-cognitive developmental outcomes. This evidence will help to understand the impact of a HAP intervention on child health to inform policies for the adoption of clean fuel in Bangladesh and other similar settings. TRIAL REGISTRATION: The Poriborton: Change trial: Household Air Pollution and Perinatal and early Neonatal mortality is registered with the Australian New Zealand Clinical Trials Registry, ACTRN12618001214224, original trial registered on 19th July 2018, extension approved on 23rd June 2021. www.anzctr.org.au .

The effect of electronic job aid assisted one-to-one counselling to support exclusive breastfeeding among 0-5-month-old infants in rural Bangladesh.

Exclusive breastfeeding (EBF) for the first 6 months has established benefits, yet had slow improvements globally. Little is known about electronic job aid-assisted counselling to support EBF. As a secondary outcome of a cluster randomized controlled trial in Bangladesh, we assessed the effect of electronic job aid-supported nutrition counselling and practical demonstration on EBF. We randomized pregnant women to one of five study arms in the trial and followed mother-child dyads until 2 years of age. Community health workers (CHWs) provided breastfeeding counselling with or without prenatal and complementary nutrient supplements in all four intervention arms. The comparison arm continued with the usual practice where mothers could receive nutrition counselling at routine antenatal and postnatal care, and during careseeking for childhood illnesses. We assessed breastfeeding indicators at birth and monthly until the child was 6 months old, in both intervention and comparison arms. To evaluate the effect of nutrition counselling on breastfeeding, we combined all four intervention arms and compared them with the comparison arm. Intervention newborns had half the risk (relative risk [RR]: 0.54, 95% confidence interval [CI]: 0.39, 0.76) of receiving prelacteal feeds than those in the comparison arm. EBF declined steeply in the comparison arm after 3 months of age. EBF was 16% higher in the intervention than the comparison arm at 4 months (RR: 1.16, 95% CI: 1.08, 1.23) and 22% higher at 5 months of age (RR: 1.22, 95% CI: 1.12, 1.33). Maternal background and household characteristics did not modify the intervention effect, and we observed no difference in EBF among caesarean versus vaginal births. Breastfeeding counselling and practical demonstration using an electronic job aid by CHWs are promising interventions to improve EBF and are scalable into existing community-based programmes.

Protocol for a cluster randomised controlled trial of LPG cookstoves compared to usual cooking practices to reduce perinatal mortality and morbidity in rural Bangladesh called Poriborton: the CHANge trial.

BACKGROUND: Household air pollution is a leading health risk for global morbidity and mortality and a major health risk in South Asia. However, there are no prospective investigations of the impact of household air pollution on perinatal morbidity and mortality. Our trial aims to assess the impact of liquefied petroleum gas (LPG) for cooking to reduce household air pollution exposure on perinatal morbidity and mortality compared to usual cooking practices in Bangladesh. HYPOTHESIS: In a community-based cluster randomised controlled trial of pregnant women cooking with LPG throughout pregnancy, perinatal mortality will be reduced by 35% compared with usual cooking practices in a rural community in Bangladesh. METHODS: A two-arm community-based cluster randomised controlled trial will be conducted in the Sherpur district, Bangladesh. In the intervention arm, pregnant women receive an LPG cookstove and LPG in cylinders supplied throughout pregnancy until birth. In the control or usual practice arm, pregnant women continue their usual cooking practices, predominately traditional stoves with biomass fuel. Eligible women are pregnant women with a gestational age of 40-120 days, aged between 15 and 49 years, and permanent residents of the study area. The primary outcome is the difference in perinatal mortality between the LPG arm and the usual cooking arm. Secondary outcomes include (i) preterm birth and low birth weight, (ii) personal level exposure to household air pollution, (iii) satisfaction and acceptability of the LPG stove and stove use, and (iv) cost-effectiveness and cost-utility in reducing perinatal morbidity and mortality. We follow up all women and infants to 45 days after the birth. Personal exposure to household air pollution is assessed at three-time points in a sub-sample of the study population using the MicroPEM™. The total required sample size is 4944 pregnant women. DISCUSSION: This trial will produce evidence of the effectiveness of reduced exposure to household air pollution through LPG cooking to reduce perinatal morbidity and mortality compared to usual cooking practices. This evidence will inform policies for the adoption of clean fuel in Bangladesh and other similar settings. TRIAL REGISTRATION: Australian New Zealand Clinical Trials Registry ACTRN12618001214224 . Prospectively registered on 19 July 2019.

Wealth- and education-related inequalities in minimum dietary diversity among Indonesian infants and young children: a decomposition analysis.

BACKGROUND: Over the last two decades, Indonesia has experienced remarkable economic growth. However, the percentage of infants and young children meeting the minimum dietary diversity (MDD) criteria has stagnated. Despite the growing body of evidence of the association between MDD and socioeconomic factors, there is little information about socioeconomic inequalities in MDD in Indonesia. OBJECTIVES: The current study seeks to quantify the wealth- and education-related inequalities in MDD among infants and young children in Indonesia and determine the contribution of different factors to these disparities. METHODS: We included a total of 5038 children aged 6-23 months of the 2017 Indonesia Demographic and Health Survey. We measured wealth- and education-related inequalities using the concentration curve and Wagstaff normalised concentration index. Using a concentration index decomposition analysis, we then examined factors contributing to wealth- and education-related inequalities in MDD. RESULTS: The concentration indices by household wealth and maternal education were 0.220 (p < 0.001) and 0.192 (p < 0.001), respectively, indicating more concentration of inequalities among the advantaged population. The decomposition analysis revealed that household wealth (29.8%), antenatal care (ANC) visits (16.6%), paternal occupation (15.1%), and maternal education (11.8%) explained the pro-rich inequalities in MDD in Indonesia. Maternal education (26.1%), household wealth (19.1%), ANC visits (14.9%), and paternal occupation (10.9%) made the most considerable contribution to education-related inequalities in MDD. CONCLUSIONS: There is substantial wealth- and education-related inequalities in MDD. Our findings suggest an urgent need to address the underlying causes of not reaching dietary diversity by promoting infant and young child feeding equity in Indonesia.

The impact of a package of behaviour change interventions on breastfeeding practices in East Java Province, Indonesia.

Suboptimal infant young child feeding practices are frequently reported globally, including in Indonesia. This analysis examined the impact of a package of behaviour change interventions on breastfeeding practices in Malang and Sidoarjo Districts, East Java Province, Indonesia. The BADUTA study (which in the Indonesian Language is an acronym for BAwah DUa TAhun, or children aged less than 2 years) was an impact evaluation using a cluster-randomized controlled trial with two parallel treatment arms. We conducted household surveys in 12 subdistricts from Malang and Sidoarjo. We collected information from 5175 mothers of children aged 0-23 months: 2435 mothers at baseline (February 2015) and 2740 mothers at endline (January to February 2017). This analysis used two indicators for fever and diarrhoea and seven breastfeeding indicators (early initiation of breastfeeding, prelacteal feeding, exclusive breastfeeding under 6 months, predominant breastfeeding, continued breastfeeding, age-appropriate breastfeeding and bottle-feeding). We used multilevel logistic regression analysis to assess the effect of the intervention. After 2 years of implementation of interventions, we observed an increased odds of exclusive breastfeeding under 6 months (adjusted odds ratio [aOR] = 1.85; 95% confidence interval [CI]: 1.35-2.53) and age-appropriate breastfeeding (aOR = 1.39; 95% CI: 1.07-1.79) in the intervention group than in the comparison group, at the endline survey. We found significantly lower odds for prelacteal feeding (aOR = 0.52; 95% CI: 0.41-0.65) in the intervention than in the comparison group. Our findings confirmed the benefits of integrated, multilayer behaviour change interventions to promote breastfeeding practices. Further research is required to develop effective interventions to reduce bottle use and improve other breastfeeding indicators that did not change with the BADUTA intervention.

Effect of a peer-led education intervention on dietary behaviour and physical activity among adolescents in Ho Chi Minh City, Vietnam: a pilot study.

This pilot study aimed to evaluate the effectiveness of peer-led education intervention on physical activity, sedentary behaviours, and dietary behaviours among adolescents in HCM city, Vietnam. Among students in the intervention arm after a 9-month follow-up, total energy intake was reduced by 304 kcal/day, fat by 13 g/day, carbohydrate by 39 g/day, and sweet foods by 20 g/day, compared to pre-intervention figures (p < 0.05, adjusted for age, BMI at baseline, gender, the interaction between measurement time and intervention groups, and cluster effect in schools). Only total energy intake was significantly lower in the intervention than control students (p < 0.05, after adjustment). Our pilot project has established the feasibility of a peer-led intervention to improve lifestyles among adolescents in HCM city and evidence of improvements in dietary intake. Australian New Zealand Clinical Trials Registry: ACTRN12619000421134.