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Growing the Evidence for Nutrition Programming

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Growing the Evidence for Nutrition Programming GROWING THE EVIDENCE FOR NUTRITION PROGRAMMING: PERCEPTIONS, IMPLEMENTATION, AND UPTAKE OF A PACKAGE OF LIPID- BASED SUPPLEMENTATION AND BEHAVIOR CHANGE COMMUNICATION INTERVENTIONS IN MALAWI by Julie Catherine Ruel-Bergeron, MPH A dissertation submitted to Johns Hopkins University in conformity with the requirements for the degree of Doctor of Philosophy. Baltimore, Maryland June, 2017 © 2017 Julie C. Ruel-Bergeron All rights reserved Abstract Background: Childhood undernutrition continues to be a problem of public health significance in low and middle-income countries (LMIC), holding consequences for children’s physical and cognitive development that contributes to lower economic earnings and increased morbidity in adulthood. Efficacious interventions to improve child growth during the critical window of opportunity, from conception to 2 years of age, include nutrition education to promote optimal infant and young child feeding (IYCF) practices, and supplementation with fortified foods, such as lipid-based nutrient supplements, among others. The delivery of these interventions in a programmatic context so that they yield improvements in child nutritional status, however, proves to be difficult given the logistical and sociocultural challenges associated with the delivery and uptake of interventions. Understanding how programs work to improve child nutrition and feeding behaviors is critical for scaling up nutrition interventions globally. Objective: To study how a nutrition program in rural Malawi was perceived, accepted, implemented, and taken up, and whether high adherence to program interventions resulted in improved child growth and feeding behaviors after 1 year of implementation. Methods: The nutrition program in Malawi includes: (1) the monthly distribution of a daily, small-quantity (20g) lipid-based nutrient supplement, Nutributter (Nutriset, Malaunay, France) to all children 6-23 months; and (2) a social behavior change communication (SBCC) campaign to promote optimal IYCF and water, sanitation, and hygiene (WASH) practices. The program is monitored by monthly attendance tracking of target beneficiaries, and quarterly post-distribution monitoring (PDM) surveys to assess product utilization and IYCF and WASH knowledge. An independent impact evaluation ii was led by the Johns Hopkins University’s Center for Human Nutrition (JHU CHN) to measure IYCF and WASH practices, and child nutrition outcomes after 1 and 3 years of implementation in the program (Ntchisi) and a comparison (Dowa) district. A qualitative study employed in-depth interviews (IDI) with mothers (n=34) and household members (fathers, n=11; and grandmothers, n=4), focus group discussions (FGD) with village leaders (1 with n=11) and program staff (3 FGD with n=12, n=10, and n=11), and direct observations of mothers and their children (n=12), to elicit beneficiary and community perceptions of the program’s intervention components. Recorded interviews and FGDs were simultaneously transcribed and translated verbatim, and inductive line-by-line coding was conducted. Results were presented using a hybrid of the Socio Ecological Model and Transactional Theory. A process evaluation study measured the program’s conformity to its original design using various data sources to measure: program recruitment (n=21,456 children tracked through attendance records from the first year of implementation), program fidelity (n=28 direct observations of program activities; n=84 knowledge questionnaires with program staff; 8 PDM surveys with pooled n=2,901 and 2 annual performance review documents); and program reach (n=41,617 children’s attendance records for years 0-3 of implementation). Process indicators were categorized as “working well” (>75%), “needing improvement” (25%-75%), and “not working” (<25%). Impact evaluation data collected at 1 year post-program implementation (midline) (n=2,047) was linked with individual-level program attendance data (n=846) to generate high and low participation for Nutributter distributions (>71.4% and ≤71.4%, respectively) and SBCC messaging (SBCC score≥2 and SBCC score=1, respectively); iii those who were not exposed served as the referent category for each program component n=1,208 and n=204, respectively). Household, individual, and maternal characteristics were analyzed to examine their association with program exposure, using multinomial logistic regression. Varying levels of program participation were analyzed to examine the association with anthropometric (length-for-age (LAZ), weight-for-age (WAZ), weight- for-length z-scores (WLZ) and stunting, underweight, and wasting, defined as LAZ, WAZ, and WLZ <-2, respectively), IYCF, and WASH outcomes, using multivariable linear and logistic regression for continuous and binary outcomes, respectively. All linear and logistic models adjusted for household, maternal, and individual characteristics. Results: Results from the qualitative study demonstrated that Nutributter was viewed positively by all members of the household and community. Mothers and community members reported perceiving changes in child health and growth, ascribing them to Nutributter. Barriers to the monthly collection of Nutributter were competing household tasks and obligations, such as caring for ill family members or attending funerals. When asked to discuss program messages, a majority of mothers demonstrated limited and superficial knowledge of the IYCF and WASH messages. This, in combination with the described lack of financial and physical access to nutritious foods promoted by those messages were perceived as significant barriers to enacting desired behavioral changes among mothers. The process evaluation indicated that only 20.7% of children were registered into the program at or by 6 months of age. Direct observations of Nutributter distributions demonstrated that most procedures were functioning at 85% or higher, with some areas needing improvement, such as the conduct of multiple counseling sessions throughout iv distributions to account for latecomers. Despite the relatively high implementation of training activities as planned (73.3%) for frontline staff, the completion of training modules for breastfeeding (22.9%) and complementary feeding (18.6%) was low. Nevertheless, knowledge of key IYCF, WASH, and Nutributter messages among those who were trained on those messages was high, with the exception of being able to list the 6 food groups (22.9%). Over 3 years of implementation, the program reached a mean (SD, range) of 81.0% (8.5, 65.6%-93.5%) of eligible beneficiaries during monthly Nutributter distributions and 92.1% of mothers with group counseling activities, but only 32.9% (8.0, 18.8%-42.0%) of mothers with individual-level SBCC. Using multivariable models, socioeconomic characteristics (land and livestock ownership) and child morbidity (7-day diarrhea and malaria) were positively associated with high vs. no participation in Nutributter distributions (all p<0.05). Maternal age, working in agriculture as a primary occupation, and childhood acute respiratory infection were positively associated with exposure to SBCC (all p<0.05), while food insecurity was associated with lower risk of high exposure to SBCC. The dose-response analysis showed that high and low participation in Nutributter distributions was associated with higher WLZ of 0.21 (95% CI 0.01, 0.31) and 0.17 (95% CI 0.06, 0.36), respectively among children, (both p<0.05) relative to the control children. However, the confidence intervals for each were overlapping, suggesting the lack of a true dose response relationship. Program exposure was not associated with any of the other measures of nutritional status, including LAZ and WAZ, or stunting, wasting and underweight. Low and high exposure to SBCC were associated with increases (p<0.05) in dietary diversity score of 0.22 (95% CI 0.03,0.41) and 0.21 (95% CI 0.01, 0.42), respectively, and higher v likelihood of achieving minimum meal frequency (OR=1.62, 95% CI) compared to no exposure. Conclusions: This study demonstrated that the large-scale nutrition program in Ntchisi was well implemented and accepted, and that higher doses of exposure yielded improvements in some anthropometric and IYCF outcomes. The detailed documentation of the perceptions, facilitators and barriers to, implementation, characteristics associated with exposure to program components, and intermediate impact of the large-scale nutrition program generates important lessons for current and future policy, programming, and scale-up of nutrition interventions in this, and other similar contexts in sub-Saharan Africa. DISSERTATION COMMITTEE MEMBERS: Parul Christian (Advisor), DrPH, Professor, International Health Kristen Hurley, PhD, Assistant Professor, International Health Rebecca Heidkamp, PhD, Assistant Scientist, International Health David Dowdy (Chair), MD, Associate Professor, Epidemiology Kristin Mmari, DrPH, Associate Professor, Population, Family, and Reproductive Health ALTERNATE DISSERTATION COMMITTEE MEMBERS: Joel Gittelsohn, PhD, Professor, International Health Lawrence Cheskin, MD, Associate Professor, Health, Behavior, Society vi Acknowledgements I would like to express my deepest and most sincere appreciation to my advisor, Dr. Parul Christian, who guided me through this often challenging process with poise and patience. I am especially thankful for her perseverance and attention to my needs as a student, despite her shift towards a new opportunity and career path. I continue to be incredibly admirable of the
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