Age differences in the impact of a Positive Deviance/Hearth programme on the nutritional status of children in rural Bangladesh.

OBJECTIVE: To examine the difference in the rehabilitation rate from underweight by child age at enrolment in the Positive Deviance (PD)/Hearth programme. DESIGN: This secondary data analysis used programme monitoring records of underweight children aged 6-60 months attending a 2-week PD/Hearth session and followed up for 6 months from September 2018 to March 2019. Data were analysed using multilevel mixed-effect regression and Poisson regression with robust variance. SETTING: Rajshahi Division, Bangladesh. PARTICIPANTS: A total of 5227 underweight (weight-for-age Z-score (WAZ) <-2) children attended the PD/Hearth sessions. RESULTS: From enrolment to 6 months follow-up, the mean WAZ improved from -2·80 to -2·09, and the percentage of underweight children decreased to 54·5 %. Compared to the enrolment age of 6-11 months, the estimated monthly change in WAZ at 6 months of follow-up were 0·05 lower for 12-23 months, 0·06 lower for 24-35 months, and 0·09 lower for 36-60 months of the enrolment age (all P < 0·001). The probability of rehabilitation at 6 months of follow-up were lower by 16·7 % for 12-23 months (RR = 0·83; 95 % CI 0·77, 0·91), 15·5 % for 24-35 months (RR = 0·84; 95 % CI 0·78, 0·92), and 34·9 % for 36-60 months of the enrolment age (RR = 0·65; 95 % CI 0·59, 0·72), compared to the enrolment age of 6-11 months. CONCLUSIONS: Enrolment in the PD/Hearth programme at a younger age had the advantage of greater rehabilitation from underweight than older age. Our findings provide a better understanding of the successes and failures of the PD/Hearth programme to achieve more sustainable and cost-effective impacts.

Evaluation of mobile phone-based Positive Deviance/Hearth child undernutrition program in Cambodia.

Child undernutrition in Cambodia is a persistent public health problem requiring low-cost and scalable solutions. Rising cellphone use in low-resource settings represents an opportunity to replace in-person counselling visits with phone calls; however, questions remain on relative effectiveness. Our objective was to evaluate the impact of two options for delivering a World Vision infant and young child feeding (IYCF) counselling programme: (1) traditional Positive Deviance/Hearth (PDH) programme with in-person visits or (2) PDH with Interactive Voice Calling (PDH-IVC) which integrates phone calls to replace 62.5% of face-to-face interaction between caregivers and volunteers, compared to the standard of care (SOC). We conducted a longitudinal cluster-randomised controlled trial in 361 children 6-23 months. We used an adjusted difference-in-difference approach using baseline, midline (3 months) and endline (12 months) surveys to evaluate the impact on child growth among the three groups. At baseline, nearly a third of children were underweight, and over half were food insecure. At midline the PDH group and the PDH-IVC groups had improved weight-for-age z-scores (0.13 DID, p = 0.011; 0.13 DID, p = 0.02, respectively) and weight-for-height z-score (0.16 DID, p = 0.038; 0.24 DID, p = 0.002), relative to SOC. There were no differences in child height-for-age z-scores. At endline, the impact was sustained only in the PDH-IVC group for weight-for-age z-score (0.14 DID, p = 0.049), and the prevalence of underweight declined by 12.8 percentage points (p = 0.036), relative to SOC. Integration of phone-based IYCF counselling is a potentially promising solution to reduce the burden of in-person visits; however, the modest improvements suggest the need to combine it with other strategies to improve child nutrition.

An Innovative Grandmother-Inclusive Approach for Addressing Suboptimal Infant and Young Child Feeding Practices in Sierra Leone.

BACKGROUND: Suboptimal infant and young child feeding (IYCF) practices contribute to child undernutrition. Sierra Leone Demographic and Health Survey data show that IYCF practices remain poor despite modest improvements. Recent studies have identified the role of grandmothers as critical to child nutrition; however, in Sierra Leone to date, the potential for grandmothers to influence IYCF practices has not been investigated. OBJECTIVES: We examined how an innovative grandmother-inclusive approach (GMIA) can be used to address suboptimal IYCF practices. METHODS: Using a quasi-experimental design, we compared IYCF beliefs and practices between GMIA intervention communities (receiving monthly dialogue sessions on nutrition, quarterly community praise sessions, and intergenerational forums) and comparison communities (receiving standard nutrition education) in Bum chiefdom from 2013 and 2016. The quantitative endline survey targeted 101 pregnant women, 291 women with children aged <2 y, and 219 grandmothers. Statistical analyses utilized t tests and χ2 tests to examine differences between intervention and comparison communities at endline. Multivariate regression was used to determine the intervention's effect on IYCF outcomes of interest. RESULTS: Awareness of and participation in the GMIA was high among mothers and grandmothers in intervention communities. The percentage of infants and young children aged 0-23 mo (n = 291) exclusively breastfed during the first week of life was significantly higher in the intervention group (90.2% compared with 79.4%, P = 0.01). Among infants aged 6-23 mo (n = 219), the percentage achieving minimum dietary diversity and minimum acceptable diet was significantly higher in the intervention group (77.2% compared with 51.8%, P < 0.001; and 53.8% compared with 22.6%, P < 0.001, respectively). Differences in percentages achieving minimum meal frequency (MMF) were only significant for infants aged 9-23 mo, with the intervention group achieving a higher MMF (54.6% compared with 36.9%, P = 0.02). CONCLUSIONS: Results suggest that a GMIA that recognizes grandmothers' roles and strengthens their knowledge can contribute to improved IYCF practices.

Bobbi Be Best: the development and evaluation of an audio program and discussion guide to promote exclusive breastfeeding in Cameroon, Central Africa.

One risk factor for infant and childhood morbidity is not exclusive breastfeeding (EBF) during the first six months of life. Entertainment Education (EE) is a communication strategy consisting of placing educational information into television, movies, and radio programs. In developing countries this form of behavioral change communication has proven effective in addressing health-related issues; however, no research has determined if EE is effective in promoting EBF. The objective of this research was to develop an EE audio program and discussion guide and to determine if a series of four 15-minute episodes and post-listening discussion improved knowledge, perceived benefits, self-efficacy, and intention and decreased misconceptions and perceived barriers toward EBF in the Kumbo West Health District, Cameroon. Pregnant women and their partners were assigned to either the control group (N = 116; 74 women, 42 partners) or intervention group (N = 148; 99 women, 49 partners) based on expected date of delivery. All control and intervention group participants completed a questionnaire prior to listening to the first and after the last episode. Pre- and post-listening questionnaires were used to determine changes in the EBF knowledge, misconceptions, perceived barriers, self-efficacy, and intention variables as a result of exposure to the audio program. The Wilcoxon Sign Rank test showed significant improvement in all of the variables, except perceived barriers, within the intervention group (p < 0.05) and the Mann-Whitney test indicated significant differences between the control and intervention group in all of the variables (p < 0.05), indicating that using an audio program and discussion guide based on the EE model is an effective tool for promoting EBF in this setting. The strength of this approach is that it goes beyond simply telling women about what constitutes EBF, but addresses misconceptions and perceived barriers that may prevent women from practicing EBF for six months.

Incorporating cultural beliefs in promoting exclusive breastfeeding.

INTRODUCTION: Since 2003, the World Health Organization has recommended exclusive breastfeeding for the first 6 months of life. In the Northwest region of Cameroon approximately 90% of women initiate breastfeeding, yet only 34% of these women exclusively breastfeed for the recommended six months. AIM: To determine influences on women's exclusive breastfeeding practices. METHODS: Semi-structured interviews were conducted with six women and six men followed by focus group discussions with three groups of women and three groups of men in the Kumbo West Health District, Northwest region, Cameroon. All participants were selected using theoretical sampling to assure triangulation. RESULTS: Three themes emerged that influence exclusive breastfeeding practices: woman's readiness to exclusively breastfeed; cultural influences towards exclusive breastfeeding; and perceived constraints to exclusive breastfeeding. CONCLUSION: These emergent themes were used to create a theoretical framework that is useful for developing a breastfeeding health education intervention in non-Western settings.