Adherence and acceptability of community-based distribution of micronutrient powders in Southern Mali.

Home fortification with micronutrient powders (MNP) has been shown to reduce anaemia, with high overall acceptability and adherence, but there is limited evidence from West Africa. Around 80% of children younger than 5 years are anaemic in Mali, and new interventions are needed. This paper reports on the adherence and acceptability of a community-led MNP intervention targeting children aged 6-59 months in Southern Mali. The MNP were delivered by a multidisciplinary group of community volunteers using community-based preschools, cooking demonstrations, and traditional communication networks to promote MNP, nutrition, hygiene, and child stimulation. The MNP were delivered alongside early childhood development interventions and seasonal malaria chemoprevention. Adherence and acceptability were evaluated through two cross-sectional surveys in 2014 and 2016 and a qualitative evaluation in 2015. Over 80% of parents reported ever having given MNP to their child, with 65% having given MNP for four or more days in the last week. Likely contributors to uptake include: perceived positive changes in the children following MNP use, the selection of a food vehicle that was already commonly given to children (morning porridge or bouillie) and the community driven, decentralized and integrated delivery approach. These findings support recommendations from recent reviews of MNP implementation to use community-based delivery approaches and behaviour change components.

Using a Community-Based Early Childhood Development Center as a Platform to Promote Production and Consumption Diversity Increases Children's Dietary Intake and Reduces Stunting in Malawi: A Cluster-Randomized Trial.

Background: Children in Malawi face nutritional risks related to low-quality diets and chronic malnutrition. Objective: This study evaluated the impact of a 1-y early childhood development (ECD) center-based agriculture and nutrition intervention aimed at improving household production diversity, maternal knowledge on child nutrition and feeding practices, and children's diets and anthropometric measures. Methods: A longitudinal cluster-randomized controlled trial was implemented in 60 community-based childcare centers (CBCCs), covering 1248 preschool children (aged 36-72 mo) and 304 younger siblings (aged 6-24 mo). CBCCs were randomly assigned to 1) a control group providing the Save the Children's ECD program or 2) a treatment group providing a standard ECD program with additional activities to improve nutritious food production and behavior change communication to improve diets and care practices for young children. Primary outcomes were household production and production diversity, preschooler enrollment and attendance, and dietary intake measured by quantitative 24-h recall and minimum diet diversity for younger siblings. Secondary outcomes included anthropometric measures for preschoolers and younger siblings, child development scores for preschoolers, and women's asset ownership and time use (the latter 2 are not discussed in this article). We used difference-in-difference (DID) estimates to assess impacts. Results: Compared with the control group, preschool children in the intervention group had greater increases in nutrient intakes and in dietary diversity. No impacts on anthropometric measures were seen in preschoolers. Younger siblings in the intervention group had greater increases in height-for-age z scores than did children in the control group (DID: 0.44; P < 0.05) and greater reductions in the prevalence of stunting (DID: -17 percentage points; P < 0.05). The plausibility of the impact on growth in younger siblings was supported by effects along program impact pathways, including production of nutritious foods, caregiver knowledge, and dietary diversity. Conclusion: Implementing an integrated agriculture and nutrition intervention through an ECD platform benefited children's diets and reduced stunting among younger siblings of targeted preschoolers. This trial was registered on the ISRCTN registry as ISCRCTN96497560.

Impact of school-based malaria case management on school attendance, health and education outcomes: a cluster randomised trial in southern Malawi.

Introduction: Evidence indicates children who suffer from ill-health are less likely to attend or complete schooling. Malaria is an important cause of morbidity and mortality in school-age children. However, they are less likely to receive malaria treatment at health facilities and evidence for how to improve schoolchildren's access to care is limited. This study aimed to evaluate the impact of a programme of school-based malaria case management on schoolchildren's attendance, health and education. Methods: A cluster randomised controlled trial was conducted in 58 primary schools in Zomba District, Malawi, 2011-2015. The intervention, implemented in 29 randomly selected schools, provided malaria rapid diagnostic tests and artemisinin-based combination therapy to diagnose and treat uncomplicated malaria as part of basic first aid kits known as 'Learner Treatment Kits' (LTK). The primary outcome was school attendance, assessed through teacher-recorded daily attendance registers and independent periodic attendance spot checks. Secondary outcomes included prevalence of Plasmodium spp infection, anaemia, educational performance, self-reported child well-being and health-seeking behaviour. A total of 9571 children from standards 1-7 were randomly selected for assessment of school attendance, with subsamples assessed for the secondary outcomes. Results: Between November 2013 and March 2015, 97 trained teachers in 29 schools provided 32 685 unique consultations. Female schoolchildren were significantly more likely than male to seek a consultation (unadjusted OR=1.78 (95% CI 1.58 to 2.00). No significant intervention effect was observed on the proportion of child-days recorded as absent in teacher registers (n=9017 OR=0.90 (95% CI 0.77 to 1.05), p=0.173) or of children absent during random school visits-spot checks (n=5791 OR=1.09 (95% CI 0.87 to 1.36), p=0.474). There was no significant impact on child-reported well-being, prevalence of Plasmodium spp, anaemia or education scores. Conclusion: Despite high community demand, the LTK programme did not reduce schoolchildren's absenteeism or improve health or education outcomes in this study setting. Trial registration number: ClinicalTrials.gov NCT02213211.

Can anthropometry measure gender discrimination? An analysis using WHO standards to assess the growth of Bangladeshi children.

OBJECTIVE: To examine the potential of anthropometry as a tool to measure gender discrimination, with particular attention to the WHO growth standards. DESIGN: Surveillance data collected from 1990 to 1999 were analysed. Height-for-age Z-scores were calculated using three norms: the WHO standards, the 1978 National Center for Health Statistics (NCHS) reference and the 1990 British growth reference (UK90). SETTING: Bangladesh. SUBJECTS: Boys and girls aged 6-59 months (n 504 358). RESULTS: The three sets of growth curves provided conflicting pictures of the relative growth of girls and boys by age and over time. Conclusions on sex differences in growth depended also on the method used to analyse the curves, be it according to the shape or the relative position of the sex-specific curves. The shapes of the WHO-generated curves uniquely implied that Bangladeshi girls faltered faster or caught up slower than boys throughout their pre-school years, a finding consistent with the literature. In contrast, analysis of the relative position of the curves suggested that girls had higher WHO Z-scores than boys below 24 months of age. CONCLUSION: Further research is needed to help establish whether and how the WHO international standards can measure gender discrimination in practice, which continues to be a serious problem in many parts of the world.

'The bigger the better'--mothers' social networks and child nutrition in Andhra Pradesh.

OBJECTIVE: It is hypothesised that mothers' social networks can positively affect child nutrition through the sharing of health knowledge and other resources. The present study describes the composition of mothers' networks, examines their association with child nutrition, and assesses whether health knowledge is shared within networks. DESIGN AND SETTING: Cross-sectional data for mothers of young children from Andhra Pradesh (south India) were combined with existing data from the Young Lives study, in which the mothers were participating (n = 282). RESULTS: The composition of social networks varied between urban and rural areas, with urban networks being larger, more female, more literate and with a greater proportion of members living outside the household and being non-family. There was a positive association between child's height-for-age Z-score and mother's network size and network literacy rate. The association with network literacy was stronger among the poorest households. Women commonly reported seeking or receiving health advice from network members. CONCLUSION: Big and literate social networks are associated with better child nutrition, especially among the poor. The dissemination of health knowledge between network members is a plausible way in which social networks benefit child nutrition in India. Further research into the underlying mechanisms is necessary to inform the development of interventions that channel health information through word of mouth to the most excluded and vulnerable families.

A randomised trial in Mali of the effectiveness of weekly iron supplements given by teachers on the haemoglobin concentrations of schoolchildren.

OBJECTIVE: To assess the effect on the haemoglobin concentrations of schoolchildren of weekly iron tablets administered by teachers. DESIGN: Sixty schools were randomly assigned to two groups: in 30 schools children were given weekly for 10 weeks a tablet providing 65 mg of iron and 0.25 mg of folic acid; in the other 30 schools no iron tablets were given. All children were dewormed and given vitamin A before the study began. The haemoglobin concentration of up to 20 randomly selected children in each school was estimated before and 2 weeks after the end of treatment. SETTING: Rural community schools in Kolondieba district of Mali. SUBJECTS: Some 1113 schoolchildren aged 6-19 years with a mean of 11.4 years. RESULTS: The haemoglobin concentration of treated children rose on average by 1.8 g l(-1) and the prevalence of anaemia fell by 8.2%; in untreated children the haemoglobin concentration fell by an average of -2.7 g l(-1) and the prevalence of anaemia rose by 9.4%. The fall in haemoglobin concentration among untreated girls of -4.0 g l(-1) was greater than in untreated boys (-0.3 g l(-1) ). CONCLUSIONS: Weekly iron tablets given by teachers prevented a general fall in the haemoglobin concentrations of untreated children, and led to a small but statistically significant rise among treated children. Young children benefited more than children aged >or=12 years, and girls benefited more than boys.

Ill-health reported by schoolchildren during questionnaire surveys in Ghana, Mozambique and Tanzania.

BACKGROUND: Insufficient attention has been paid to the health problems of school-age children in sub-Saharan Africa. A questionnaire administered to schoolchildren about their ill-health has been developed to identify schools in which urinary schistosomiasis occurs. The data collected during the interviews can also be used to assess other common health problems. OBJECTIVES: To analyse data collected during health questionnaires in schools to assess how schoolchildren perceive their own health, and to compare the findings between three countries in sub-Saharan Africa. METHODS: Questionnaires asking about recent health problems were administered by teachers to schoolchildren in 120 primary schools in Mozambique, 52 primary schools in Tanzania and 298 primary schools in Ghana. A total of 67 002 children aged 8-15 years took part. RESULTS: Of the 10 health problems asked about in all questionnaires, the average number reported by each child was 3.9 in Ghana, 3.4 in Mozambique and 3.1 in Tanzania. The distributions of the prevalence of each condition among schools were similar and the prevalence of all conditions showed a similar ranking. For most conditions a greater percentage of girls than boys reported each health problem. CONCLUSIONS: Schoolchildren in Ghana, Mozambique and Tanzania do not perceive themselves to be healthy. The pattern of reported health problems was similar in each country. School health questionnaires are worthy of further study and validation.