Can people-centered community-oriented interventions improve skilled birth attendance? Evidence from a quasi-experimental study in rural communities of Cambodia, Kenya, and Zambia.

BACKGROUND: Skilled attendance at delivery is a key marker for reducing maternal mortality. Effective community engagement strategies complemented by community health worker (CHW) services can improve access to maternal health services in areas with limited health infrastructure or workforce. METHODS: A quasi-experimental study with matched comparison groups was conducted in Cambodia, Kenya and Zambia to determine the effect of integrated community investments on skilled birth attendance (SBA). In each country, communities in two districts/sub-districts received a package of community-oriented interventions comprised of timed CHW household health promotion for maternal, newborn and child health complemented by social accountability mechanisms using community scorecards. Two matched comparison districts/sub-districts received ongoing routine interventions. Data from the final evaluation were examined to determine the effect of timed CHW services and community-oriented interventions on SBA. RESULTS: Over 80% of the 3037 women in Cambodia, 2805 women in Kenya and 1171 women in Zambia reported SBA. Women in intervention sites who received timely CHW health promotion and social accountability mechanisms in Cambodia showed significantly higher odds of SBA (aOR = 7.48; 95% CI: 3.87, 14.5). The findings also indicated that women over the age of 24 in Cambodia, women with primary or secondary education in Cambodia and secondary education in Kenya, women from higher wealth quintiles in Cambodia, and women with four or more antenatal care (ANC) visits in all countries reported significantly higher odds of SBA. Inclusion of family members in pregnancy-related discussions in Kenya (aOR = 2.12; 95% CI: 1.06, 4.26) and Zambia (aOR = 6.78; 95% CI: 1.15, 13.9) and follow up CHW visits after a referral or health facility visit (aOR = 2.44; 95% CI: 1.30, 4.60 in Cambodia; aOR = 2.17; 95% CI 1.25, 3.75 in Kenya; aOR = 1.89; 95% CI: 1.05, 2.02 in Zambia) also showed significantly greater odds of SBA. CONCLUSIONS: Enhancing people-centered care through culturally appropriate community-oriented strategies integrating timely CHW health promotion and social accountability mechanisms shows some evidence for improving SBA during delivery. These strategies can accelerate the achievement of the sustainable development goals for maternal child and newborn health.

Morbidity and nutrition status of rural drug-naïve Kenyan women living with HIV.

This paper describes morbidity in a group of HIV-positive drug-naïve rural women in western Kenya. A total of 226 drug-naïve HIV-positive women were evaluated for baseline morbidity, immune function, and anthropometry before a food-based nutrition intervention. Kenyan nurses visited women in their homes and conducted semi-structured interviews regarding symptoms and physical signs experienced at the time of the visit and during the previous week and physical inspection. Blood and urine samples were examined for determination of immune function (CD4, CD8, and total lymphocyte counts), anaemia, malaria, and pregnancy status. Intradermal skin testing with tuberculin (PPD), candida, and tetanus toxoid antigens was also performed to evaluate cell-mediated immunity. Anthropometry was measured, and body mass index (BMI) was calculated. Seventy-six per cent of the women reported being sick on the day of the interview or within the previous week. Illnesses considered serious were reported by 13.7% of women. The most frequent morbidity episodes reported were upper respiratory tract infections (13.3%), suspected malaria (5.85%), skeletal pain (4.87%), and stomach pain (4.42%). The most common morbidity signs on physical inspection were respiratory symptoms, most commonly rhinorrhea and coughing. Confirmed malaria and severe diarrhea were significantly associated with a higher BMI.

High-nutrition biscuits to increase animal protein in diets of HIV-infected Kenyan women and their children: a study in progress.

BACKGROUND: Preliminary evidence suggests that improved nutrition early in HIV infection may delay progression to AIDS and delay the initiation or improve the effectiveness of antiretroviral drug therapy. There are few studies that evaluate food-based interventions in drug-naïve, HIV-infected women and their children. Meat provides several nutrients identified as important in maintaining immune function and lean body mass. OBJECTIVE: To design supplemental meat and soybean biscuits for use in a randomized trial examining the effect of meat in the diet of drug-naïve, HIV-infected rural Kenyan women on changes in weight, lean body mass, morbidity, nutritional status, and activities of daily living of the women and growth and development of their children. METHODS: We designed three supplemental biscuits: one with added dried beef another with added soybean flour, and a wheat biscuit to serve as a control biscuit to be used in a randomized feeding intervention in drug-naïve, HIV-infected rural Kenyan women and their children. The nutritional contents of the different types of biscuit were examined and compared. RESULTS: The three biscuits were isocaloric. Meat biscuits provided more lysine, vitamin B12, and bioavailable zinc. Soybean biscuits provided more total and absorbable iron; however, higher fiber and phytate contents may inhibit nutrient absorption. Data analysis for clinical outcomes of the trial is ongoing. CONCLUSIONS: The "biscuit model" is useful for nutrition supplementation studies because it can be provided in a blinded and randomized fashion, safely and privately in a home under directly observed consumption by a highly stigmatized population. It is well received by adults and children, and the biscuits can be produced locally with available, simple, affordable technology.

Determinants of stunting and overweight among young children and adolescents in sub-Saharan Africa.

BACKGROUND: Stunting and overweight are nutritional problems affecting most of sub-Saharan Africa. The region now has the world's highest rate of stunting among children (43%), while overweight and obesity are becoming a global epidemic, and Africa is not spared. The past two decades have seen a dramatic increase in obesity in sub-Saharan Africa. OBJECTIVE: The purpose of this systematic review is to explore the determinants of stunting and overweight in sub-Saharan Africa. METHODS: A literature search was conducted in PubMed using the key words stunting, overweight, obesity, Africa, sub-Saharan Africa, determinants, and prevalence. Limits were set to include articles published between 1990 and 2012. The systematic review resulted in 38 studies, and after selection based on title, content, and country of the study, 18 studies were eligible for this review. Data were analyzed by the chi-square test. RESULTS: The prevalence rates of stunting and overweight were dependent on socioeconomic, demographic, and environmental factors. Many studies indicate that male children and those living in a rural setting are more likely to be stunted, whereas overweight among children depends more on age, household composition, occupation of the mother, and the mother's body mass index. Stunting occurred together with overweight among both boys and girls from 1 to 5 years of age. Stunting was more prevalent among boys than among girls. Indicators of socioeconomic status, such as mother's education, mother's occupation, and household income, were some of the determinants directly linked to stunting, whereas environmental factors, such as rural or urban setting and sanitation, influenced both stunting and overweight. Concurrent stunting and overweight is influenced by maternal and household factors, such as maternal height, age, and education, large household size, and lower socioeconomic status. CONCLUSIONS: Although socioeconomic, demographic, and environmental factors were significant in determining stunting and overweight, other factors, such as nutrition and lifestyle, were important risk factors. Stunting in childhood is a risk factor that may result in overweight and obesity later in adolescence and adulthood, indicating the need to screen children below 1 year of age to identify stunting early in life. Promoting exclusive breastfeeding is reported to be important in preventing both stunting and overweight among children. More research is needed to explore the relationship between stunting and overweight and to explore policy guidelines to address the phenomenon.

A comparative study of adult and adolescent maternal care continuum following community-oriented interventions in Cambodia, Guatemala, Kenya, and Zambia.

BACKGROUND: The coverage for reproductive care continuum is a growing concern for communities in low- income economies. Adolescents (15-19 years) are often at higher odds of maternal morbidity and mortality due to other underlying factors including biological immaturity, social, and economic differences. The aim of the study was to examine a) differences in care-seeking and continuum of care (4 antenatal care (ANC4+), skilled birth attendance (SBA) and postnatal care (PNC) within 24h) between adult (20-49 Years) and adolescents and b) the effect of multilevel community-oriented interventions on adolescent and adult reproductive care-seeking in Cambodia, Guatemala, Kenya, and Zambia using a quasi-experimental study design. METHODS: In each country, communities in two districts/sub-districts received timed community health worker (CHW) household health promotion and social accountability interventions with community scorecards. Two matched districts/sub-districts were selected for comparison and received routine healthcare services. RESULTS: Results from the final evaluation showed that there were no significant differences in the care continuum for adolescents and adults except for Kenya (26.1% vs 18.8%, p<0.05). SBA was significantly higher for adolescents compared to adult women for Guatemala (64% vs 55.5%, p<0.05). Adolescents in the intervention sites showed significantly higher ANC utilization for Kenya (95.3% vs 84.8%, p<0.01) and Zambia (87% vs 72.7%, p<0.05), ANC4 for Cambodia (83.7% vs 43.2%, p<0.001) and Kenya (65.9% vs 48.1%, p<0.05), SBA for Cambodia (100% vs 88.9%, p<0.05), early PNC for Cambodia (91.8% vs 72.8%, p<0.01) and Zambia (56.5% vs 16.9%, p<0.001) compared to the comparison sites. However, the findings from Guatemala illustrated significantly lower care continuum for intervention sites (aOR:0.34, 95% CI 0.28-0.42, p<0.001). The study provides some evidence on the potential of multilevel community-oriented interventions to improve adolescent healthcare seeking in rural contexts. The predictors of care continuum varied across countries, indicating the importance of contextual factors in designing interventions.

Maternal and health care workers' perspectives on exclusive breastfeeding in the context of maternal HIV infection, in Busia county, western Kenya: a mixed methods cross-sectional survey.

BACKGROUND: World Health Organization recommends exclusive breastfeeding (EBF) for 6 months with maternal active antiretroviral therapy (ART) to prevent mother-to-child transmission (PMTCT) of HIV. However, EBF in low resource settings remains low. We explored perspectives of EBF by HIV-infected mothers and health care workers in Busia County with a high prevalence of HIV to understand factors influencing the practice. METHODS: A mixed methods cross-sectional survey using concurrent quantitative and qualitative data collection methods was conducted at PMTCT clinics. Data on socio-demography, young infant feeding practices, maternal and infant health was collected between February 2013 and August 2015 from 371 purposively sampled HIV-infected mother-infant dyads using a semi-structured questionnaire. Focus group discussions with mothers, in-depth interviews and passive observation of health care workers during interaction with mothers were conducted. Significance of difference between mothers practicing EBF or not was tested by Chi-square and Fisher's exact tests setting significance level at 5%. Qualitative data was coded and content analyzed to generate themes. RESULTS: Three hundred and forty-nine (94%) mothers practiced EBF. Maternal comprehension of EBF to PMTCT of HIV influenced choice and practice of EBF (P value = 0.019 and < 0.001 respectively). Health care workers emphasized adherence to ART and offered nutritional supplementation during EBF. Health care workers' nutritional counseling in the context of maternal HIV was poor. Mentor mothers shared their experiences with mothers and offered live case demonstrations of their successfully EBF, healthy and HIV-uninfected children. The main threats to EBF were teenage motherhood, low maternal education and working during EBF. CONCLUSIONS: EBF among HIV-infected mothers in Busia County, Kenya was high. Health education and counselling by health care workers, maternal comprehension of ART adherence to PMTCT of HIV, nutritional supplementation and mentor mothers' peer counseling using live case demonstrations of HIV-uninfected EBF children promoted and sustained practice of EBF for 6 months. Teenage motherhood, low maternal education and having to work threatened EBF.

Feeding patterns and growth of term infants in Eldoret, Kenya.

BACKGROUND: There are limited longitudinal data from developing countries on early infant feeding and growth patterns. In Kenya only 34.8% of infants are exclusively breastfed at 2 months. This finding is of concern, and further understanding of infant feeding and growth patterns is important. OBJECTIVE: To determine the feeding and growth patterns of Kenyan term infants during early infancy. METHODS: A longitudinal study was conducted. One hundred and fifty-one resource-constrained mother-infant pairs were recruited from the West Municipal Health Centre (WMHC) within 24 hours after birth, and subsequent follow-up was performed at the WMHC Maternal and Child Health Clinic. Data on baseline characteristics were collected with the use of a structured questionnaire. Data on nonbreastmilk liquids given to the infants and feeding patterns were gathered with the use of a 24-hour recall. Standard procedures were used to measure infant weight, recumbent length, and head circumference. World Health Organization (WHO) growth standards were used, and tests for variation between and within group means were performed, with alpha < .05 regarded as indicating significance. RESULTS: At 6 and 10 weeks, the prevalence of exclusive breastfeeding was 40.4% and 9.9%, respectively. The mothers cited "aids infant's digestion" (38%) as the main reason for partial breastfeeding and "breastmilk was not enough" (48%) as the main reason for predominant breastfeeding. Growth velocity based on weight was similar to that in the WHO reference group. All of the children had normal growth (z-score > -2). Mothers without knowledge about WHO/UNICEF early infant feeding recommendations and those who initiated breastfeeding more than 1 hour post partum were ninefold and eightfold more likely to start mixed feeding by 10 weeks of age, respectively. CONCLUSIONS: There is a need to accelerate awareness of optimum infant feeding recommendations and augment the rigorous practice of the WHO Ten Steps to Successful Breastfeeding.

Maternal nutritional status in pastoral versus farming communities of West Pokot, Kenya: differences in iron and vitamin A status and body composition.

BACKGROUND: Underweight and micronutrient deficiencies are sequelae of the prevailing harsh living and economic conditions of women in sub-Saharan Africa. There are few data describing maternal nutritional status in these resource-poor settings. Provision of more effective modes of intervention requires that public health and nutrition policy at both the national and the multisectoral levels be based on community-specific nutritional and behavioral practices. OBJECTIVE: This longitudinal study investigated maternal micronutrient status in two remote, semiarid, rural communities that are ethnically similar but have distinctly different pastoral and farming lifestyles. We looked at differences in iron stores, vitamin A levels, and body composition of women in the third trimester of pregnancy and again at 4 months postpartum. METHODS: Complete data were collected from 113 pastoral and 110 farming Pokot women. Anthropometric measurements were taken, and serum ferritin and retinol levels were measured. Infants were weighed within 7 days of birth. RESULTS: Women from the farming community had significantly (p < .05) lower hemoglobin concentrations than women from the pastoral community during the third trimester of pregnancy. Pastoral women had significantly higher serum ferritin concentrations than farming women during the third trimester of pregnancy (p <.05) and at 4 months postpartum. There were no significant differences between pastoral and farming women in the percentage of women with serum retinol levels < 0.70 micromol/L during the third trimester of pregnancy (27.9% [34/113] and 24.2% [31/110], respectively) and at 4 months postpartum (29.2% [33/113] and 30.9% [34/110]) In the farming community, mean infant birthweight was significantly lower (p <. 01) than in the pastoral community and a significantly higher (p < .05) proportion of newborns weighed less than 2.5 kg. At 4 months postpartum, the percentage of body fat was significantly lower in pastoral women than in farming women. CONCLUSIONS: Women from the farming community in West Pokot, Kenya, have lower iron stores during the third trimester of pregnancy than women in the pastoral community. In addition, the mean weight of their newborn infants is lower than that of infants in the pastoral community. These findings may be associated with differences in living conditions, which are usually harsher in farming than in pastoral communities.

Consumption of vitamin A by breastfeeding children in rural Kenya.

Vitamin A deficiency remains a significant health risk in developing countries, affecting infants and children in particular. To counter child malnutrition, mothers are encouraged to breastfeed to ensure that their children receive adequate macro- and micronutrients, including vitamin A. However, this assumes that the mother has sufficient vitamin A intake to provide enough vitamin A to her child. This study investigates maternal and infant intakes of locally available foods of high vitamin A content in a rural agricultural community in Kenya. The study aims to establish the community risk for vitamin A deficiency and to assess whether breast milk is adequate to maintain and build retinol reserves of the breastfed infant. The study assesses 62 mother-child pairs and employs several methods to support its objectives, including the Helen Keller International food-frequency survey, maternal and infant anthropometric measurements, and maternal breast-milk and blood samples to determine breast-milk and serum retinol levels. We found that mothers with marginal (< 0.700 micromol/l) serum retinol and breast-milk deficient (< 1.05 micromol/l) in retinol accounted for 45.2% and 77.4%, of our sample, respectively. A significant (p < 0.05) proportion (40.3%) of mothers had breast milk deficient in retinol and marginal levels of serum retinol. The risk of vitamin A deficiency in breastfed infants older than six months was high, because 89.5% of them did not consume foods high in vitamin A content three times weekly. The primary source of vitamin A for infants younger than six months was breast-milk deficient in retinol vitamin A. This study suggests that in this rural community, breastfed infants may not receive appropriate foods with high vitamin A content and that although exclusive breastfeeding is advocated, most breast milk is deficient in retinol, further heightening the risk of vitamin A deficiency.