Assessing the Impact of a Handwashing Knowledge and Practices Program among Poor Households in Rural Bangladesh: A Cluster-Randomized Pre-Post Study.

Improvement in hand hygiene has been strongly associated with positive outcomes in maternal and child health. Although Bangladesh has a high level of awareness of key hygiene messages, the practice of handwashing, the most effective hygiene behavior, is low. Suchana, a multisectoral nutrition program, aims to increase knowledge and practices around various water, sanitation, and hygiene settings in Sylhet region, the northeast of rural Bangladesh. This study aimed to investigate the changes in indicators related to handwashing knowledge and practices among Suchana beneficiaries in final compared with baseline evaluations. Data were derived from the baseline and final cross-sectional evaluation survey. The following handwashing knowledge and practices were considered: handwashing before preparing food, before eating food and feeding children, before serving food, after defecation, and after touching animals. The descriptive findings indicate that Suchana intervention improved handwashing knowledge and practices in the intervention area compared with the control. The odds of having knowledge of hand washing before preparing food (adjusted odds ratio [aOR]: 1.60; 95% CI: 1.30-1.98), before eating food and feeding children (aOR: 1.68; 95% CI: 1.25-2.25), before serving food (aOR: 1.35; 95% CI: 1.04-1.76), after defecation (aOR: 1.74; 95% CI: 1.25-2.41), and after touching animals (aOR: 1.67; 95% CI: 1.29-2.16) were higher in intervention area than the control area. Similarly, the impact on maternal handwashing practices at final evaluation indicated successful effects of the intervention. These results suggest scaling-up of similar interventions for larger populations living in vulnerable areas of rural Bangladesh.

Influence of the Suchana intervention on exclusive breastfeeding and stunting among children aged under 6 months in the Sylhet region of Bangladesh.

Exclusive breastfeeding (EBF) provides significant health benefits to children. However, mothers may find it difficult to continue EBF for 6 months. The present analysis aimed to examine the influence of the Suchana intervention-a large-scale programme implemented with the aim of improving the health and nutritional status of mothers and children from poor households in the Sylhet region of Bangladesh-on EBF and stunting among children under 6 months. Baseline and endline data were obtained from the Suchana evaluation. EBF was defined as an infant (<6 months) only receiving breast milk in the previous 24 h. Childhood stunting was defined as a length-for-age z-score of less than -2 among children of the same age. Multiple logistic regression analysis was used to assess the associations of the Suchana intervention with EBF and stunting. EBF prevalence improved from 64% at baseline to 85% at the endline in the intervention area, with the intervention group having 2.25 times higher odds of EBF compared to the control group. Stunting prevalence reduced from 28% at baseline to 24% at the endline in the intervention group, but after controlling for covariates, the association between stunting and the intervention was not significant. However, the interaction analysis showed significantly lower stunting prevalence among EBF children in both intervention and control areas. The Suchana intervention had a positive impact on the EBF practice of rural children in a vulnerable region of Bangladesh, and EBF was identified as a significant factor associated with stunting. The findings suggest that the continuation of the EBF intervention has the potential to have an impact on reducing stunting in the region, highlighting the importance of promoting EBF to improve child health and development.

A predictive modelling approach to illustrate factors correlating with stunting among children aged 12-23 months: a cluster randomised pre-post study.

OBJECTIVE: The aim of this study was to construct a predictive model in order to develop an intervention study to reduce the prevalence of stunting among children aged 12-23 months. DESIGN: The study followed a cluster randomised pre-post design and measured the impacts on various indicators of livelihood, health and nutrition. The study was based on a large dataset collected from two cross-sectional studies (baseline and endline). SETTING: The study was conducted in the north-eastern region of Bangladesh under the Sylhet division, which is vulnerable to both natural disasters and poverty. The study specifically targeted children between the ages of 12 and 23 months. MAIN OUTCOME MEASURES: Childhood stunting, defined as a length-for-age z-score <-2, was the outcome variable in this study. Logistic and probit regression models and a decision tree were constructed to predict the factors associated with childhood stunting. The predictive performance of the models was evaluated by computing the area under the receiver operating characteristic (ROC) curve analysis. RESULTS: The baseline survey showed a prevalence of 52.7% stunting, while 50.0% were stunted at endline. Several factors were found to be associated with childhood stunting. The model's sensitivity was 61% and specificity was 56%, with a correctly classified rate of 59% and an area under the ROC curve of 0.615. CONCLUSION: The study found that childhood stunting in the study area was correlated with several factors, including maternal nutrition and education, food insecurity and hygiene practices. Despite efforts to address these factors, they remain largely unchanged. The study suggests that a more effective approach may be developed in future to target adolescent mothers, as maternal nutrition and education are age-dependent variables. Policy makers and programme planners need to consider incorporating both nutrition-sensitive and nutrition-specific activities and enhancing collaboration in their efforts to improve the health of vulnerable rural populations. TRIAL REGISTRATION NUMBER: RIDIE-STUDY-ID-5d5678361809b.

Factors associated with low and medium household dietary diversity compared with high dietary diversity among marginalised households in rural Bangladesh: Findings from a Suchana baseline survey.

OBJECTIVE: This study aimed to identify the associated factors of low and medium household (HH) dietary diversity (DD) compared with high DD among marginalised households in rural Bangladesh. METHODS: Through the Suchana baseline survey, data on 5440 households from Sylhet and Moulvibazar districts of Bangladesh was collected between November 2016 and February 2017. Household DD was categorised as low, medium or high based on number of food groups consumed during the last 24 hours. Primary outcome measure was household DD; multinomial logistic regression was to determine independent correlations between outcome and independent variables. RESULTS: Of the households examined, 0.72%, 31.8% and 67.5% had low, medium and high DD, respectively. Around 99% and 97% of households consumed cereals and vegetables. Cereals, fruits and legumes accounted for 36%, 18% and 16% of total food expenditure; vegetables only represented 8% of total expenditure; 70% of total monthly expenditure was on food items. Compared with high DD, low DD was significantly associated with severe food insecurity, not receiving remittance, not being supported by social safety-net programs, household size of 6-10, household income and expenditure on food below-median. Severe food insecurity was the strongest predictor of low DD. Age, occupation and educational status of the household head, amount of land owned and presence of a homestead garden, fish production and domestic violence were not significantly associated with DD. CONCLUSION: Our findings suggest that nine out of ten households were food insecure, and nearly two-thirds of households had high DD. Severe food insecurity was significantly associated with low DD. Expenditure on food items amounted to nearly two-thirds of total household expenditure. Diversification of income-generating activities would provide more sources of income to the households, allowing the households to spend more on non-cereal food items and increase the household dietary diversity.

Food security status of Suchana-participating households in north-eastern rural Bangladesh.

Despite achieving remarkable progress, food insecurity remains a major public health challenge in Bangladesh, and severe food insecurity status has not been reduced in susceptible areas and vulnerable regions in Bangladesh. Wetlands that are susceptible to flooding can be found in Bangladesh's north-eastern Sylhet division. Suchana, a large-scale nutrition programme, implemented nutrition-specific and sensitive interventions in poor and very poor households in Sylhet and Moulvibazar districts in the north-eastern region of Bangladesh. The aim of this article is to assess the association between the Suchana intervention and household food security status among poor and very poor households in north-eastern rural Bangladesh using the Suchana baseline and endline survey databases. The baseline survey was conducted between November 2016 and February 2017, while the endline survey was undertaken 3 years later, during the same months. The outcome variable in this analysis was household food security status, which was measured using the Food and Nutrition Technical Assistance's Guideline. Descriptive statistics were used to summarize the data; after controlling for the union as a cluster and relevant covariates, a multiple multinomial logistic regression model was used to estimate the independent effect of the Suchana intervention as an exposure. Overall, 14.0% of households were food secure at the baseline survey (intervention: 14.1%, control: 14.0%) and 22.0% were food secure (intervention: 26.6%, control: 20.2%) at the endline survey. For households in the intervention area in comparison to the control area, the odds of being moderately food insecure [aOR: 1.36 (1.05, 1.76), p < 0.05], mildly food insecure [aOR: 1.83 (1.33, 2.51), p < 0.001], or food secure [aOR: 2.21 (1.47, 3.33), p < 0.001] compared to being severely food insecure was significantly higher. Thus, we infer that the 3 years of Suchana intervention marginally increased household food security status among the socio-economically disadvantaged population in north-eastern rural Bangladesh. If concerns regarding gender equity, women's education, and income-generating activities are addressed, the population could experience even greater benefits in food security. In order to overcome these challenges, all stakeholders including programme implementers and policymakers should work together to implement the appropriate measures.

Enhanced women's decision-making power after the Suchana intervention in north-eastern Bangladesh: a cluster randomised pre-post study.

OBJECTIVES: Women's decision-making power is a dimension of empowerment and is crucial for better physical and psychosocial outcomes of mothers. Suchana, a large-scale development programme in Bangladesh, actively provided social interventions on behaviour change communication to empower women belonging to the poorest social segment. This paper aims to assess the impact of the Suchana intervention on various indicators related to women's decision-making power. DESIGN, SETTING AND PARTICIPANTS: The evaluation design was a cluster randomised pre-post design with two cross-sectional surveys conducted among beneficiary women with at least one child aged <23 months from randomly selected poor or very poor beneficiary households in Sylhet division. OUTCOME MEASURE: Decision-making indicators included food purchases, major household purchases, food preparation, children's healthcare as well as women's own healthcare and visiting family and relatives. RESULTS: Our findings suggest that 45% of women were able to make decisions on food purchases, 25% on major household purchases, 78% on food preparation, 59% on children's healthcare, 51% on their own healthcare and 43% on visiting family and relatives at baseline in the intervention group, whereas the results were almost the same in the control group. In contrast, at the endline survey, the respective proportions were 75%, 56%, 87%, 80%, 77% and 67% in the intervention group, which were significantly improved when compared with the control group. The prevalence of those outcome indicators were 64%, 41%, 80%, 71%, 68% and 56%, respectively, in the control group. As per multiple logistic regression analysis and structural equation modelling, the Suchana intervention had a substantial influence on the latent variable of women's decision-making power. CONCLUSION: In terms of food purchases, major household purchases, children's healthcare, their own healthcare and visiting family and relatives, the Suchana intervention favourably influenced the decision-making power of rural women living in a vulnerable region of Bangladesh. TRIAL REGISTRATION NUMBER: RIDIE-STUDY-ID-5d5678361809b.

Does a child's mid-upper arm circumference-for-age z-score represent another nutritional indicator of childhood malnutrition status?

Child wasting is defined as a weight-for-height/length z-score (WLZ/WHZ) < -2, and this indicator of nutritional status is used worldwide. However, a precise measurement is required for the assessment of a child's nutritional status, which may not always be possible due to expensive instruments, especially in poor resource settings. In some instances, mid-upper arm circumference-for-age z-score (MUACZ) is also being used for screening purposes, which is a simple and useful nutritional indicator. The objective of this paper is to identify the optimal cut-off point for the MUACZ to identify wasted children, and also to determine if the same factors are associated with MUACZ and wasting. Data were derived from the Suchana evaluation data. The optimal cut-off value was estimated via receiver operating characteristic (ROC) curve analysis using acute malnutrition as a gold standard with maximum sensitivity and specificity. Multiple logistic regression was used to assess the associated factors with the MUACZ. Using the gold standard indicator of nonwasting (WLZ ≥ -2), a positive outcome, the optimal cut-off point for the MUACZ was -1.27. The area under the ROC curve was 0.88, indicating that the model had a power of 88% to differentiate between the positive and negative classes. It implies that a child's MUACZ was correlated with WLZ, and a MUACZ below -1.27 appeared to accurately identify wasting among children aged 3-23 months. MUACZ < -1.27 might be another useful indicator of childhood wasting than a WLZ < -2.

Stunting Status of Ever-Married Adolescent Mothers and Its Association with Childhood Stunting with a Comparison by Geographical Region in Bangladesh.

The adolescence period is considered a life stage worthy of strategic health investments since it is a critical period of physical and neuro-maturational development. Adolescent girls face different health difficulties in that phase of life. Children born to adolescent mothers are at a higher risk of undernutrition. This paper aims to estimate the prevalence of stunting among adolescent mothers and their children in Bangladesh by time period and determine the associated factors of adolescent maternal stunting status. We also sought to establish the relationship between maternal and childhood stunting by comparing the geographical regions in Bangladesh. We derived data from the nationally representative Bangladesh Demographic and Health Survey, which was conducted between 2007 and 2017/18. The outcome variables of this study were ever-married adolescent girls' stunting status and their children's stunting status. Interaction analysis between administrative division and maternal stunting status was conducted with childhood stunting as the outcome variable to investigate the impact of maternal stunting status on their children's stunting compared to geographical location. Our results indicated that in comparison to other divisions, the frequency of stunting among children and adolescent mothers was higher in the Sylhet region. It also revealed that children whose mothers were stunted had a 2.36 times increased chance of being stunted. Our study suggests that education for women could help them attain self-sufficiency and, as a result, reduce the prevalence of poor childhood nutrition, especially stunting.

Type of terrain and infant and young child feeding practices: cross-sectional study findings on children below 2 years of age from northern Bangladesh.

INTRODUCTION: Optimal feeding practices are vital for the subsistence, adequate nutrition, physical growth and mental development of infants and young children. This study aimed to examine the prevalence of core infant and young child feeding (IYCF) indicators and their associations with the type of terrain, that is, geographical area or zone among the beneficiaries of a large-scale nutrition programme, Suchana, being carried out in the northern part of rural Bangladesh. METHODOLOGY: A cross-sectional study was conducted from November 2016 to February 2017 in Sylhet and Moulvibazar districts of Sylhet Division, Bangladesh. Data pertaining to 5440 children aged below 24 months were analysed for this study. Univariate analysis was carried out to establish the prevalence of the indicators; selected variables were subjected to multiple regression model to identify independent relationships between the IYCF indicators and the type of terrain stratified as plain land, hilly area, flash-flood prone area and haor (wetland). RESULTS: In logistic regression analysis, flash-flood prone areas were significantly associated with higher exclusive breast feeding (1.92, 95% CI 1.12 to 3.30; p=0.019), minimum meal frequency (1.45, 95% CI 1.07 to 1.97; p=0.018) and minimum dietary diversity (1.63, 95% CI 1.01 to 2.63; p=0.046) compared with plain land. Moreover, hilly areas were associated with significantly lower introduction of solid, semisolid or soft foods (0.39, 95% CI 0.18 to 0.82; p=0.013) compared with plain land. CONCLUSION: The observed prevalence of the indicators can be set as benchmark while prioritising interventions aimed at improving IYCF practices among underprivileged families residing in different types of rural setting in Bangladesh.

The large-scale community-based programme 'Suchana' improved maternal healthcare practices in north-eastern Bangladesh: Findings from a cluster randomized pre-post study.

Adequate maternal healthcare practices are crucial to both maternal and infant nutrition outcomes. The Sylhet region of Bangladesh is vulnerable and performs poorly, as maternal and child health indicators are falling behind compared to other areas. Suchana, a large-scale intervention programme aims to improve the health and nutritional status of mothers and children in this region. The objective of the present analysis is to assess the changes in indicators related to maternal healthcare practices among Suchana beneficiaries. We obtained data from the Suchana baseline and endline evaluation survey. Descriptive statistics were employed to summarize data. The following maternal healthcare practices were considered: if a Suchana beneficiary mother received antenatal care (ANC) from skilled service providers, took day time resting during pregnancy, consumed additional diet during pregnancy, took at least 100 iron-folic acid (IFA) tablets during pregnancy and took a vitamin A capsule after delivery. Logistic regression analysis was performed to assess the impact of the Suchana intervention on maternal healthcare practices. The prevalence of the outcome variables at endline in the intervention area were as follows: 40% of mothers received at least four ANC from skilled service providers, 50% practiced daytime resting during pregnancy, 51% consumed additional diet during pregnancy, 41% took at least 100 iron-folic acid tablets during pregnancy, 39% received postnatal care and 30% took a vitamin A capsule after delivery. The Suchana intervention significantly, positively improved indicators related to maternal healthcare practices; these findings support future larger-scale programmes to improve maternal healthcare practices among vulnerable people in rural Bangladesh.

Iron content of drinking water is associated with anaemia status among children in high groundwater iron areas in Bangladesh.

OBJECTIVE: Iron in groundwater provides a good source of absorbable iron for humans and can contribute to optimal iron and haemoglobin (Hb) status among populations. We aimed to examine the relationship between the iron content of groundwater and anaemia status among 12- to 23-month-old children in a rural area of Bangladesh. METHOD: A cross-sectional study was conducted in 80 randomly selected unions (the lowest administrative unit) in Sylhet and Moulvibazar districts of Bangladesh. A total of 800 children aged 12-23 months were selected via a systematic random sampling method. The child's age, sex, stunting status, consumption of iron-rich or iron-fortified food, maternal age and maternal body mass index (BMI) and the type of terrain were subjected to multiple logistic regression analysis to observe the independent relationships between groundwater iron content and anaemia in children. RESULTS: In total, 50.4% of children were anaemic. The odds of children being anaemic were 1.51-fold higher [OR: 1.51 (95% CI: 1.09, 2.09)] among households consuming water with an iron content <2 mg/L than in households consuming water with an iron content ≥2 mg/L. Childhood stunting, child's sex, child's age and the type of terrain were also significantly associated with anaemia among children. CONCLUSION: Groundwater with a high iron concentration was significantly associated with a decreased risk of childhood anaemia. This study provides evidence of the importance of groundwater iron to protect impoverished young children from anaemia.