Enrollment and use of a peer counselor mHealth texting program to support breastfeeding in low-income people: A pilot study in the District of Columbia.

OBJECTIVE: To describe the characteristics of postpartum people who did and did not enroll in a breastfeeding peer-counselor mobile health (mHealth) texting program as well as the issues raised through 2-way texting with peer counselors. DESIGN: Pilot intervention study involving two Special Supplemental Nutrition Programs for Women Infants and Children (WIC) sites in the District of Columbia over 1 year. SAMPLE: WIC recipients. MEASUREMENTS: Descriptive statistics, comparison of recipients who enrolled or not and qualitative content analysis of text messages. INTERVENTION: A breastfeeding peer counselor texting program entitled BfedDC involving routine 1-way programmed messages and 2-way texting capacity for recipients to engage with peer counselors. RESULTS: Among our sample (n = 1642), nearly 90% initiated breastfeeding. A total of 18.5% (n = 304) enrolled in the BfedDC texting program, of whom 19.7% (n = 60) utilized the 2-way texting feature. Message content covered seven content themes and included inquiries about expressing human milk, breastfeeding difficulties, breastfeeding frequency and duration, appointments and more. CONCLUSIONS: Although enrollment was relatively low in BfedDC, benefits included 1-way supportive texts for breastfeeding and the ability to 2-way text with peer counselors. This program aligns with the Surgeon General's Call to Action to Support Breastfeeding and promotes breastfeeding equity in low-income people.

The Impact of COVID-19 on Breastfeeding Initiation and Duration in a Low-Income Population, Washington, DC.

Objective: To assess the impact of the coronavirus disease 2019 (COVID-19) pandemic on breastfeeding initiation (BFI) and duration among women enrolled in the Special Supplemental Nutrition Program for women, infants, and children (WIC) in Washington District of Columbia (DC). Materials and Methods: We used WIC program data from Washington DC to assess the pandemic's impact on BFI and duration among WIC recipients. t-Tests and unadjusted odds ratios compared breastfeeding outcomes before and during the pandemic. Multivariable logistic and linear regression models estimated the pandemic's impact on initiation and duration, respectively, while controlling for social determinants of health and other factors. Results: BFI was similar among women who gave birth before (61.4%) or during the pandemic (60.4%) (p = 0.359). However, the proportion of women who breastfed at 1 month decreased significantly from 56.1% (before pandemic) to 47.6% (during pandemic) (p < 0.0001). This pattern for duration continued at 3 and 6 months: 46.9% to 37.1% (p < 0.0001) at 3 months and 34.8% to 25.7% (p < 0.0001) at 6 months. On average, women who delivered during the pandemic breastfed 33.9 fewer days than those who delivered before (p < 0.0001). Conclusions: BFI among DC WIC recipients was similar for infants born before or during the pandemic, and determinants of initiation remained similar to previous reports (e.g., race/ethnicity, education). However, for women who initiated breastfeeding, average duration was significantly lower for infants born during the pandemic than before. Our findings suggest the importance of leveraging WIC and other breastfeeding supports to promote breastfeeding during pandemics and other emergencies.

Feeding Homemade Sugar Sweetened Beverages in Addition to Breastfeeding: Survey Results from Caregivers of Infants and Young Children in Peri-Urban Lima, Peru.

OBJECTIVES: Consumption of sugar sweetened beverages (SSB) is associated with childhood obesity and other negative health conditions. Feeding SSB to infants and young children (IYC) under 2 years may displace consumption of breastmilk and nutrient rich foods critical for optimal growth and development. The World Health Organization (WHO) recommends avoiding added sugar (e.g. SSB) for IYC under 2 years. We sought to describe the variety of homemade and commercial SSB as well as breastmilk and beverages without added sugar fed to IYC aged 4-23 months living in a low-income, populous peri-urban area of Lima, Peru. METHODS: A cross-sectional survey was conducted with 181 households with IYC aged 4-23 months. A list of common local homemade and commercial beverages was used to investigate what caregivers had fed to the child in the past 24 h. RESULTS: A total of 93.9% of caregivers reported feeding at least one beverage to their child other than breastmilk in the past 24 h. This included a variety of homemade SSB (73.5%), commercial SSB (18.2%) and homemade beverages without added sugar (70.2%). A high percentage (83.4%) of children were also breastfed. CONCLUSIONS FOR PRACTICE: Our findings suggest that interventions to address feeding homemade SSB to IYC within households are needed to support WHO recommendations and complement current commercial SSB policy regulations in Peru.

Predictors of missed school days among military connected families: A feasibility study.

BACKGROUND: There is a paucity of research specific to military children's health, especially those with special needs. This may be partly attributed to the difficulty in accessing military connected families as a population. Yet, given the recognized importance of military connected families to the national security agenda, a need exists for studies to explore factors underlying child and family health. PURPOSE: We sought to identify factors among a sample of military children with special health care needs (CSHCN) predictive of missed school days, a commonly used measure of health and one used by NPs to monitor chronic conditions management success. METHODOLOGY: We used a secondary data analysis design and multivariable logistic regression with a subsample of military connected families from the National Survey of CSHCN identified by their reported insurance type. RESULTS: We identified 1,656 military CSHCN. According to the adjusted model, hours of care per week, family work hours change, and activity limitations for the child were positive predictors of ≥4 missed school days per year. CONCLUSION/IMPLICATIONS: Our models identified important predictors of missed school days among military children that may inform assessments, interventions, and referrals by nurse practitioners caring for them. We identified a robust sample of military CSHCN from the National Survey of CSHCN by using self-reported insurance, a novel and simple approach to conducting a focused study of this population. Although feasible, this sampling approach was not without limitations. We advocate for including military connected families within sampling frameworks of national surveys to ensure that studies with this critical and unique population continue.

Beneficiary and Local Stakeholder Participation in Community-Based Nutrition Interventions.

Beneficiary and local stakeholder participation is an essential element to the success of community-based nutrition interventions. We sought to define active participation and review the available evidence on beneficiary and local stakeholder participation in community-based nutrition interventions in Africa. From reviewing the literature, we provide a reflective assessment on the process and findings. Participation falls on a continuum of community involvement from passive (no real involvement) to empowerment and community ownership (full active involvement). However, we found a clear gap in the research on defining active participation and identifying what constitutes active participation on behalf of beneficiaries and local stakeholders. However, progress was found; evidence included the use of participatory methods to engage beneficiaries and local stakeholders in the assessment and design phase. Beneficiary and local stakeholder participation in delivering interventions has moved forward with quantitative measures from process evaluation and implementation science. Research has started on the extent of beneficiary engagement (as recipients) and connecting this to outcomes. Evaluation has benefited from qualitative inquiry with insights from participants on engagement itself, and the barriers and facilitators to engagement. Yet questions remain in each study phase around defining and quantifying active participation and in understanding the personal, social, and motivational elements of active participation. We offer a simple framework to stimulate thought and commitment to research on participation in community-based nutrition interventions.

Disparities in Breastfeeding Initiation Among African American and Black Immigrant WIC Recipients in the District of Columbia, 2007-2019.

Objectives. To estimate differences in breastfeeding initiation (BFI) rates between African Americans and Black immigrants enrolled in the District of Columbia Special Supplemental Nutrition Program for Women, Infants and Children (WIC) between 2007 and 2019. Methods. We used data collected as part of routine WIC program activities for first-time mothers (n = 38 142). Using multivariable logistic regression models, we identified determinants of BFI for African Americans, Black immigrants, non-Hispanic Whites, and Hispanics. To assess the trend in BFI over time, we calculated the average of the annual percentage changes. Results. Compared with African Americans, Black immigrants had a 2.7-fold higher prevalence and Hispanics had a 5.8-fold higher prevalence of BFI. The average of the annual percentage changes was 0.85 for Hispanics, 3.44 for Black immigrants, 4.40 for Non-Hispanic Whites, and 4.40 for African Americans. African Americans had the only statistically significant change (P < .05). Disparities in BFI persisted over the study period, with African Americans demonstrating the lowest rates each year. Conclusions. Significant differences exist in BFI between Black immigrants and African Americans. Combining African Americans and Black immigrants masks important differences, overestimates rates among African Americans, and may lead to missed opportunities for targeting interventions and policies to improve breastfeeding. (Am J Public Health. 2022;112(4):671-674. https://doi.org/10.2105/AJPH.2021.306652).

Smoking and Race Associated with Decreased Breastfeeding Initiation and Duration Among a Low Income Population.

Objectives: To assess associations between smoking behaviors during pregnancy and postpartum and breastfeeding initiation and duration, among DC Women, Infants, and Children (WIC) recipients, the majority of whom are non-White, controlling for sociodemographic factors, low birth weight (LBW), and delivery in a Baby-Friendly hospital (BFH). Materials and Methods: A series of ordinary least squares and logistic regressions estimated the association between smoking during pregnancy and postpartum on breastfeeding initiation and duration, respectively. A multilevel modeling approach accounted for WIC site effects. Results: Overall, 8.8% of DC WIC recipients smoked during pregnancy. Smoking during pregnancy and postpartum was negatively associated with breastfeeding initiation (adjusted odds ratio [aOR] = 0.47, 95% confidence interval [CI]: 0.36, 0.61) and duration (adjusted coefficient [B] = -37.96, 95% CI: -62.92, -13.00) in adjusted models, respectively. Maternal age, race, marital status, LBW, and delivery in a BFH were also significantly associated with initiation, while age, race, and marital status were significantly associated with duration. Likewise, the number of cigarettes smoked per day was negatively associated with initiation (aOR = 0.79, 95% CI: 0.72, 0.87) and duration (B = -8.98, 95% CI: -15.55, -2.41) in adjusted models. Conclusions: Both smoking and number of cigarettes smoked during pregnancy and postpartum are significant factors associated with less breastfeeding in the DC WIC population. Furthermore, smoking cessation during pregnancy shows initial promise to increase breastfeeding initiation. Future research is needed to better understand the role of smoking, relapse, and cessation interventions on breastfeeding rates among low-income, predominantly minority populations.

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

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

Rigor in PhD dissertation research.

Recent reports from the Institute of Medicine document the increase in the number of nurses enrolled in doctoral education preparing for nurse scientist and leadership roles in the transformation of health care. This means that many doctoral students will acquire a knowledge of the research process, learn how to review and critique relevant literature, select appropriate research designs, and with the guidance of their dissertation chair and committee, design and conduct high quality, scholarly research studies that culminate in successfully defended doctoral dissertations. The health care profession expects that these dissertations, which include quantitative, qualitative, or mixed methods, will contribute to the knowledge base of the nursing profession and advance improvement in clinical and public health outcomes in the populations served by the nursing profession. This article reviews the concept of rigor in research, the rationale for rigor, various approaches that increase rigor, and the associated concepts that strengthen a research study.

Healthy Habits Questionnaire Feasibility and Utility for High-Risk Children.

The American Academy of Pediatrics provides guidance for pediatric primary care providers to promote healthy weight during childhood. Screening questions on diet and activity habits can help provider assessment and assist counseling for targeted behavior change. We implemented the parent completed, 10-item 5210 Healthy Habits Questionnaire (Ages 2-9 year) in our primary care practice serving low-income minority children with high rates of overweight and obesity. Adherence to the intervention protocol was high, and providers found the content and method of assessment useful for their counseling of individual patients. The aggregate Healthy Habits Questionnaire data provided a snapshot of the health habits in our local clinic population of children, prompting greater awareness for providers and informing their patient care.

Determinants of Breastfeeding Initiation and Duration Among African American DC WIC Recipients: Perspectives of Recent Mothers.

BACKGROUND: In Washington, DC, African American women receiving the Special Supplemental Nutrition Program for Women, Infants and Children (WIC) benefits have the lowest breastfeeding rates compared with other WIC-eligible populations. OBJECTIVES: The purpose of this research was to use the social cognitive theory and elements of social support as a guiding framework to better understand the factors affecting breastfeeding initiation and duration among African American WIC recipients in low-income areas of Washington, DC. METHODS: Semistructured interviews were conducted with 24 women receiving WIC services in DC to learn about their infant feeding practices and decisions. Using a pragmatic approach, an integrated inductive and deductive coding strategy was used. RESULTS: Breastfeeding experiences were influenced by barriers at multiple levels: community (i.e., perceptions of breastfeeding in one's network), interpersonal (i.e., few supportive providers), and individual constraints (i.e., pain, supply, and latching issues) as well as environmental difficulties of finding resources to help overcome these challenges. Social support from a close family member, friend, or partner often helped to minimize many of these barriers and facilitated breastfeeding. CONCLUSIONS: Social support seems to bolster efficacy and help women to overcome various barriers to breastfeeding in their immediate environment; however, social support from providers was limited. WIC offers recipients in DC many helpful breastfeeding resources. Although several respondents were aware of these resources, overall use in the sample was low. Continued outreach may help further facilitate breastfeeding in African American mothers by providing additional sources of social support.

Identification of Overweight and Obesity in Low-Income Minority Children by Pediatric Providers and Child Characteristics Associated With Underrecognition.

INTRODUCTION: Childhood overweight and obesity remains prevalent. We sought to identify characteristics associated with correct coding of obese and overweight children ages 2-9 years by pediatric primary care providers (PCPs) in an urban, minority clinic. METHOD: Samples included electronic health records pre- (n = 262) and post- (n = 244) provider training to implement an intervention aiming to improve consistency in obesity prevention and management guidelines from 15 providers. Analysis included descriptive statistics and simple logistic regression. RESULTS: Child characteristics consistently associated with correct coding in both pre- and post-intervention included children with obese body mass index percentiles (vs. overweight) and older-aged children (vs. toddlers). Provider characteristics were not associated. DISCUSSION: Improvements in coding overweight and obese children occurred post-intervention, yet many were missed. Knowledge of characteristics associated with missed coding can inform targeted training for PCPs to implement evidence-based obesity guidelines with full fidelity for all families.

Social Support for Breastfeeding in the Era of mHealth: A Content Analysis.

BACKGROUND: Several barriers to successful breastfeeding exist, including a lack of support from peers or professionals. With the emergence of mobile health (mHealth) tools to provide additional breastfeeding support, a more thorough review of social support resources was needed. Research Aim: The aim of this study was to determine mHealth breastfeeding support resources and characterize the type of social support they provide. METHODS: A content analysis of mHealth programs ( n = 65), including text messaging ( n = 12) and mobile applications ( n = 53), was conducted on the basis of searches of the iTunes and Google Play stores ( n = 50) and PubMed, the Cumulative Index of Nursing and Allied Health, and American Business Information/INFORM Complete Plus ( n = 15). Results were then dual-coded for key characteristics and types of support provided. RESULTS: Thirty-eight apps (76%) were free to users, 14 (28%) were offered in a variety of languages, and 47 (94%) provided informational support. The mobile applications were targeted largely to postpartum women, focused on breastfeeding duration, and included troubleshooting information. Mobile applications often included media components ( n = 12 [24%]); few were tailored or personalized ( n = 5 [10%]) and interactive ( n = 15 [30%]). Text-messaging programs were available in a variety of countries ( n = 7 [58%]) and provided mostly informational support ( n = 5 [42%]), were pro-breastfeeding ( n = 12 [100%]), were targeted to both pregnant and postpartum women ( n = 6 [50%]), focused on both breastfeeding initiation and duration ( n = 9 [75%]), and had two-way interactivity ( n = 6 [50%]) and personalization ( n = 5 [42%]). CONCLUSIONS: Although freely available mobile applications and text-messaging programs exist, with potential for wide reach, the majority provide only informational support. These programs would benefit from additional study of their usefulness.

Modifying Provider Practice To Improve Assessment of Unhealthy Weight and Lifestyle in Young Children: Translating Evidence in a Quality Improvement Initiative for At-Risk Children.

BACKGROUND: We designed a quality improvement (QI) project to address the high prevalence of childhood overweight and obesity (OW/OB) in our patient population and the inconsistencies among primary care providers in recognizing and addressing OW/OB. METHODS: We used mixed methods data collection approach to evaluate a QI project, the Childhood Healthy Behaviors Intervention (CHBI), to improve provider obesity prevention practice in two low-income, predominantly African American pediatric primary care clinics. Electronic record data were extracted from all 2-9 year well visits pre- and postintervention for frequency of appropriate diagnostic coding of OW/OB. We reviewed a random sample of records for details of health habit assessment and counseling documentation. Focused interviews were conducted to elicit provider responses regarding impressions of the intervention. RESULTS: The preintervention sample of records (n = 267) was extracted from 18 providers and the postsample (n = 253) from 19 providers. Providers showed improvement in the recognition of OW/OB with appropriate diagnostic coding (52% pre, 68% post), improvement in assessment of health habits informed by the habit survey (0% pre, 76% post), improvement in counseling of healthy behaviors (86% pre, 92% post), and improvement in goal setting of healthy behaviors (12% pre, 70% post). CONCLUSIONS: Our findings suggest that implementing a time efficient primary care intervention with brief provider training can improve provider recognition of OW/OB, as well as improve provider behavior targeted at childhood obesity prevention. This project contributes needed QI evidence on interventions to prevent and address OW/OB in primary care settings and calls for further work to strengthen implementation in similar contexts.

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

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

Implementation examined in a health center-delivered, educational intervention that improved infant growth in Trujillo, Peru: successes and challenges.

Process evaluation was used to examine the implementation of a randomized, controlled trial of an education intervention that improved infant growth in Trujillo, Peru. Health personnel delivered the multi-component intervention as part of usual care in the government health centers. Quantitative and qualitative methods were used to examine process indicators, which included the extent of delivery (dose), fidelity to intervention protocol, barriers to implementation and context. Results demonstrated that most intervention components were delivered at a level of 50-90% of expectations. Fidelity to intervention protocol, where measured, was lower (28-70% of expectations). However, when compared with existing nutrition education, as represented by the control centers, significant improvements were demonstrated. This included both improved delivery of existing educational activities as well as delivery of new intervention components to strengthen overall nutrition education. Barriers to, and facilitators of, implementation were explored with health personnel and helped to explain results. This study demonstrates the importance of examining actual versus planned implementation in order to improve our understanding of how interventions succeed. The information gained from this study will inform future evaluation designs, and lead to the development and implementation of more effective intervention programs for child health.

The cost-effectiveness of a child nutrition education programme in Peru.

This article reports impact and cost results from a health facility-based nutrition education programme targeting children less than 2 years of age in Trujillo, Peru. Key elements of the programme included participative complementary feeding demonstrations, growth monitoring sessions and an accreditation process. Data were collected from six intervention and six control health facilities to measure utilization and costs associated with the intervention. To calculate the unit costs of services, these costs are allocated using activity-based costing. To measure the effects of the intervention, 338 children were followed through household surveys at regular intervals from birth until the age of 18 months. The intervention had a clear positive impact both on the use of nutrition-related services and on children's growth outcomes. Children in the intervention areas made 17.6 visits to health facilities in the first 18 months of life, compared with 14.1 visits for children in the control areas (P < 0.001). This pattern holds true for all socioeconomic groups. The intervention prevented 11.1 cases of stunting per 100 children. In multivariate logistic regression analysis, children in the intervention were 0.33 times as likely to be stunted as the controls (P = 0.002). The marginal cost of the intervention - including external costs, training, health education materials and extra travel and equipment - is 6.12 US dollars per child reached and 55.16 US dollars per case of stunting prevented. The estimated marginal cost of the intervention per death averted is 1952 US dollars.

Process evaluation determines the pathway of success for a health center-delivered, nutrition education intervention for infants in Trujillo, Peru.

Process evaluation was used to explain the success of a randomized, controlled trial of an educational intervention to improve the feeding behaviors of caregivers and the nutritional status of infants in Trujillo, Peru. Health personnel delivered a multicomponent intervention within the environment of usual care at government health centers. We created a model of the expected intervention pathway to successful outcomes. Process data were then collected on health center implementation of the intervention and caregiver reception to it. Using multivariate models, we found that variables of health center implementation, caregiver exposure, and caregiver message recall were all significant determinants in the pathway leading to improved feeding behaviors. These outcomes were consistent with our original intervention model. Further support for our model arose from the differences in caregiver reception between intervention and control centers. Process data allowed us to characterize the pathway through which an effective nutrition intervention operated. This study underscores the importance of including process evaluation, which will lead to the development and implementation of more effective nutrition interventions.

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

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