Care groups in an integrated nutrition education intervention improved infant growth among South Sudanese refugees in Uganda's West Nile post-emergency settlements: A cluster randomized trial.

OBJECTIVE: This study examined the effects of a peer-led integrated nutrition education intervention with maternal social support using Care Groups on infant growth among South Sudanese refugees in Uganda. METHODS: A community-based cluster-randomized trial (RCT) was conducted among 390 pregnant women (third trimester). Two intervention study arms were Mothers-only(n = 131) and Parents-combined (n = 142) with a Control (n = 117). WHO infant growth standards defined length-for-age z-scores (LAZ) for stunting, weight-for-age z-scores (WAZ) for underweight and weight-for-length z-scores (WLZ) for wasting. The Medical Outcomes Study (MOS) social support index was a proxy measure for social support. A split-plot ANOVA tested the interaction effects of social support, intervention, and time on infant growth after adjusting for covariates. Further, pairwise comparisons explained mean differences in infant growth among the study arms. RESULTS: The mean infant birth weight was 3.1 ± 0.5 kg. Over the study period, infant stunting was most prevalent in the Control (≥ 14%) compared to Mothers-only (< 9.5%) and Parents-combined (< 7.4%) arms. There were significant interaction effects of the Care Group intervention and social support by time on infant mean LAZ (F (6, 560) = 28.91, p < 0.001), WAZ (F (5.8, 539.4) = 12.70, p = < 0.001) and WLZ (F (5.3, 492.5) = 3.38, p = 0.004). Simple main effects by the end of the study showed that the intervention improved infant mean LAZ (Mothers-only vs. Control (mean difference, MD) = 2.05, p < 0.001; Parents-combined vs. Control, MD = 2.00, p < 0.001) and WAZ (Mothers-only vs. Control, MD = 1.27, p < 0.001; Parents-combined vs. Control, MD = 1.28, p < 0.001). CONCLUSION: Maternal social support with an integrated nutrition education intervention significantly improved infant stunting and underweight. Nutrition-sensitive approaches focused on reducing child undernutrition among post-emergency refugees may benefit from using Care Groups in programs. TRIAL REGISTRATION: Clinicaltrials.gov, NCT05584969.

A Peer-Led Integrated Nutrition Education Intervention through Care Groups Improved Complementary Feeding of Infants in Postemergency Settlements in the West-Nile Region in Uganda: A Cluster Randomized Trial.

Background: Complementary feeding of infants in refugee settlements remains inadequate. Furthermore, there has been limited evaluation of interventions addressing these nutrition challenges. Objective: This study examined the effects of a peer-led integrated nutrition education intervention on infant complementary feeding by South Sudanese refugee mothers in the West-Nile region in Uganda. Methods: A community-based randomized trial enrolled 390 pregnant women (during third trimester) as the baseline. Two arms [mothers-only and parents-combined (both mothers and fathers)] comprised treatments with a control. Infant feeding was assessed using WHO and UNICEF guidelines. Data were collected at Midline-II and Endline. The medical outcomes study (MOS) social support index was used to measure social support. An overall mean score of >4 was considered optimal social support, a score of ≤2 was none or little support. Adjusted multivariable logistic regression models determined the effects of the intervention on infant complementary feeding. Results: At the end of the study, infant complementary feeding improved significantly in both mothers-only and parents-combined arms. There was a positive effect on the introduction of solid, semisolid, and soft foods (ISSSF) in the mothers-only arm at both Midline-II {adjusted odds ratio (AOR) = 4.0]} and Endline (AOR = 3.8). Likewise, ISSSF was better for the parents-combined arm at both Midline-II (AOR = 4.5) and Endline (AOR = 3.4). Minimum dietary diversity (MDD) was significantly better at the Endline for the parents-combined arm (AOR = 3.0). Minimum acceptable diet (MAD) was significantly better at Endline for both mothers-only (AOR = 2.3) and parents-combined arms (AOR = 2.7). Infant consumption of eggs and flesh foods (EFF) was improved only in the parents-combined arm at both Midline-II (AOR = 3.3) and Endline (AOR = 2.4). Higher maternal social support was associated with better infant MDD (AOR = 3.3), MAD (AOR = 3.6), and EFF (AOR = 4.7). Conclusion: Engaging both fathers and mothers in care groups benefited complementary feeding of infants. Overall, this peer-led integrated nutrition education intervention through care groups improved infant complementary feeding in the West-Nile postemergency settlements in Uganda.This trial was registered at clinicaltrials.gov as NCT05584969.

Breastfeeding among South Sudanese refugees in protracted settlements in Adjumani district, Uganda: facilitators and barriers.

BACKGROUND: Evidence suggests that forced migration and refugee status may adversely impact mothers' breastfeeding choices. Furthermore, suboptimal breastfeeding practices have been reported among vulnerable populations including those living in refugee settlements. Therefore, this study investigated the barriers and facilitators of breastfeeding in protracted settlements in Adjumani district, in the West Nile region in Uganda. METHODS: This study was conducted among refugees living in protracted settlements located in Uganda in July 2019. Participants, originally from South Sudan, included mothers (n = 63) and fathers (n = 32) of children less than 24 months of age. Agojo, Ayilo-I, and Nyumanzi were randomly selected among the 17 refugee settlements in Adjumani. Participants formed a total of six focus group discussions (FGDs); four FGDs for mothers and two FGDs for fathers. Each FGD consisted of 15-16 participants. Data were transcribed verbatim and back-translated into English. Thematic analysis was used and data were analyzed using NVivo, v. 12. RESULTS: Facilitators of breastfeeding included knowledge of breastfeeding benefits, support from husband/father, support from the community, and support from non-governmental organizations. Mothers and fathers noted that breastfeeding protected children from diseases and breastfed children grew well. Fathers, the community, and organizations provided material support for breastfeeding mothers. Four themes were identified as barriers to breastfeeding: physical, socioeconomic, knowledge, and psychosocial. Mothers and fathers described physical barriers such as mothers stop breastfeeding when they are sick or they feel they are not producing enough breastmilk. Mothers reported that working or educated mothers may use other milk to feed their infant. Some mothers and fathers believed infants under six months needed more than breastmilk. Fathers described psychosocial barriers such as mothers' fear of pain during breastfeeding and maternal mental health issues. CONCLUSION: Interventions and policies that aim to improve breastfeeding in protracted settlements should consider addressing the barriers to breastfeeding at each level: physical, socioeconomic, knowledge, and psychosocial. Involving and encouraging support from husbands/fathers, relatives, and the community may increase adherence to breastfeeding recommendations.

Realization of the right to adequate food and the nutritional status of land evictees: a case for mothers/caregivers and their children in rural Central Uganda.

BACKGROUND: In developing countries like Uganda, the human right to adequate food (RtAF) is inextricably linked to access to land for households to feed themselves directly through production or means for its procurement. Whether RtAF is enjoyed among Ugandan land evictees, is unknown. We therefore explored this among land evictees (rights-holders) in Wakiso and Mpigi districts in rural Central Uganda. We assessed food accessibility and related coping strategies, diet quality and nutritional status of children 6-59 months old, and their caregivers. Effectiveness of the complaint and redress mechanisms in addressing RtAF violations was also explored. METHODS: In this cross-sectional study, quantitative data was collected using a structured questionnaire, with food security and nutritional assessment methods from a total of 215 land evictees including 187 children aged 6-59 months. Qualitative data was collected by reviewing selected national and international documents on the RtAF and key informant interviews with 15 purposively sampled duty-bearers. These included individuals or representatives of the Uganda Human Rights Commission, Resident District Commissioner, Sub-county Chiefs, and local Council leaders. RESULTS: We found that 78% of land evictees had insufficient access to food while 69.4% had consumed a less diversified diet. A majority of evictees (85.2%) relied on borrowing food or help from others to cope with food shortages. Of the 187 children assessed, 9.6% were wasted, 18.2% were underweight and 34.2% were stunted. Small, but significant associations, were found between food accessibility, diet quality, food insecurity coping strategies; and the nutritional status of evictees. We observed that administrative, quasi-judicial and judicial mechanisms to provide adequate legal remedies regarding violations of the RtAF among evictees in Uganda are in place, but not effective in doing so. CONCLUSION: Land eviction without adequate legal remedies is a contributor to food insecurity and undernutrition in rural Central Uganda. It is essential that the Government strengthens and enforces the policy and legal environment to ensure adequate and timely compensation of evictees in order to reduce their vulnerability to food insecurity.

Environmental, dietary and case-control study of Nodding Syndrome in Uganda: A post-measles brain disorder triggered by malnutrition?

Nodding Syndrome (NS) is an epileptic encephalopathy characterized by involuntary vertical head nodding, other types of seizures, and progressive neurological deficits. The etiology of the east African NS epidemic is unknown. In March 2014, we conducted a case-control study of medical, nutritional and other risk factors associated with NS among children (aged 5-18years) of Kitgum District, northern Uganda (Acholiland). Data on food availability, rainfall, and prevalent disease temporally related to the NS epidemic were also analyzed. In NS Cases, the mean age of reported head nodding onset was 7.6years (range 1-17years). The epidemiologic curve of NS incidence spanned 2000-2013, with peaks in 2003 and 2008. Month of onset of head nodding was non-uniform, with all-year-aggregated peaks in April and June when food availability was low. Families with one or more NS Cases had been significantly more dependent on emergency food and, immediately prior to head nodding onset in the child, subsistence on moldy plant materials, specifically moldy maize. Medical history revealed a single significant association with NS, namely prior measles infection. NS is compared with the post-measles disorder subacute sclerosing panencephalitis, with clinical expression triggered by factors associated with poor nutrition.

Contribution of forest foods to dietary intake and their association with household food insecurity: a cross-sectional study in women from rural Cameroon.

OBJECTIVE: To determine the contribution of forest foods to dietary intake and estimate their association with household food insecurity. DESIGN: Cross-sectional survey conducted among 279 households. Using a 7 d recall questionnaire, information on household food consumption was collected from women and used to determine the household dietary diversity score, food variety score and forest food consumption score (FFCS). Household Food Insecurity Access Scale (HFIAS) score was determined and Spearman rank correlation was used to establish the relationship between consumption of forest foods and HFIAS score. Women's dietary intake was estimated from two 24 h recalls. The contribution of forest foods to women's nutrient intakes was calculated and women's nutrient intakes were compared with estimated average nutrient requirements. SETTING: Rural forest-dependent households in twelve villages in eastern and southern Cameroon. SUBJECTS: Household heads and their non-pregnant, non-lactating spouses. RESULTS: Forty-seven unique forest foods were identified; of these, seventeen were consumed by 98 % of respondents over the course of one week and by 17 % of women during the two 24 h recall periods. Although forest foods contributed approximately half of women's total daily energy intake, considerably greater contributions were made to vitamin A (93 %), Na (100 %), Fe (85 %), Zn (88 %) and Ca (89 %) intakes. Despite a highly biodiverse pool of foods, most households (83 %) suffered from high food insecurity based on the HFIAS. A significant inverse correlation was observed between the HFIAS score and the FFCS (r 2=-0·169, P=0·0006), demonstrating that forest foods play an important role in ensuring food security in these forest-dependent communities. CONCLUSIONS: Forest foods are widely consumed by forest-dependent communities. Given their rich nutrient content, they have potential to contribute to food and nutrition security.

Factors influencing consumption of nutrient rich forest foods in rural Cameroon.

Studies show that a number of forest foods consumed in Cameroon are highly nutritious and rich in health boosting bioactive compounds. This study assessed the knowledge and perceptions towards the nutritional and health promoting properties of forest foods among forest dependent communities. The relationship between knowledge, perceptions and socio-demographic attributes on consumption of forest foods was also determined. A total of 279 females in charge of decision making with respect to food preparation were randomly selected from 12 villages in southern and eastern Cameroon and interviewed using researcher administered questionnaires. Multivariate logistic regression analysis was used to identify the factors affecting consumption of forest foods. Baillonella toxisperma (98%) and Irvingia gabonesis (81%) were the most known nutrient rich forest foods by the respondents. About 31% of the respondents were aware of the nutritional value and health benefits of forest foods. About 10%-61% of the respondents expressed positive attitudes to questions related with health benefits of specific forest foods. Consumption of forest foods was found to be higher among polygamous families and also positively related to length of stay in the forest area and age of respondent with consumption of forest foods. Education had an inverse relationship with use of forest foods. Knowledge and positive attitude towards the nutritional value of forest foods were also found to positively influence consumption of forest foods. Since knowledge was found to influence attitude and consumption, there is need to invest in awareness campaigns to strengthen the current knowledge levels among the study population. This should positively influence the attitudes and perceptions towards increased consumption of forest foods.

Nutrition Education to Improve Dietary Intake and Micronutrient Nutriture among Children in Less-Resourced Areas: a Randomised Controlled Intervention in Kabarole District; Western Uganda

Objective: To determine whether nutrition education targeting the child-feeding practices of low- income rural caregivers will reduce anaemia and improve vitamin A nutriture of the young children in their care.Design: A controlled intervention trial; based on experiential learning theory. Forty-six women completed a nine-session nutrition education programme; while controls (n = 43) concurrently engaged in sewing classes.Setting: Two rural farming communities in the Kabarole district; western Uganda.Subjects: Less literate; low-income rural female caregivers and the children in their care (6-48 months).Outcome measures: Caregivers' child-feeding practices and the children's nutritional status were assessed at baseline; one month after intervention (Follow-up 1) and one year from baseline (Follow-up 2).Results: Caregivers in the intervention group reported improved child snacking patterns; food-selection practices; meal adequacy; and food variety. Children in the intervention group recorded lower haemoglobin levels at baseline (9.86 vs. 10.70 g/dl) and caught up with controls at Follow-up 1 (10.06 vs. 10.78 g/dl). However; changes were not sustained. Mean retinol-binding protein improved from 0.68 ?mol/l (95 CI: 0.57-0.78) to 0.91 ?mol/l (95 CI: 0.78-1.03) among intervention children; but remained approximately the same in controls. Vitamin A nutriture was influenced by infections.Conclusion: Nutrition education significantly improved feeding practices and children's nutritional status. The effectiveness and sustainability of this programme can be enhanced if nutrition education is integrated into other food-production and public health programmes