Impact of Food Security Interventions& Nutrition Education on Child Dietary

DiversityResults from 3 Cross-sectional

SurveysThe IMCF Team

at the 2nd ECAMA SymposiumMalawi Institute of Management

Lilongwe04 June 2015

Improving Infant & Young Child Feeding

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Background – as of 2011

Inappropriate feeding practices during the complementary feeding

period contribute to inadequate nutrient intake among infants &

young children

Even when food resources are available in the home, caregivers are

not able to make the best use of them:

Inadequate knowledge

Unhealthy beliefs & practices

Inappropriate advice

Need for interventions to improve quality of complementary foods by

promoting consumption of a variety of foods, including local foods

Lack of evidence!

IFSN Project

To improve food security & nutrition:

• Support to joint nutrition education between Agriculture and Health

for increased impact of knowledge and skills on: production,

processing, storage and utilization including improved

complementary feeding practices

• Distribution of a range of agricultural inputs to vulnerable

households including those with young children and pregnant

women

• Increased diversification of local production to include different

livestock and nutritious food crops covering the six food groups

Key Activities

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Promote diversified agriculture to improve availability, access and utilization of all six food groups

Capacity building of farmers, lead farmers, frontline staff

Promote income generating activities: fruit trees, apiary, mushrooms, vegetables, cassava, Irish potatoes, orange-fleshed sweet potatoes

Promotion of environment, soil & water conservation

Improve water & sanitation

Promotion of small scale irrigation-gravity fed, treadle pumps, residual moisture

Objectives of the Research Project …

… was to test the following hypotheses:

1. TIPs formative research generates behaviour

change communication messages & nutritionally

improved recipes that lead to lasting improvements in

complementary feeding practices, dietary intakes &

child nutritional status

2. Locally available & affordable foods can provide a

significant contribution to the nutritional requirements of

children 6-23 months6

3. Nutrition education with focus on IYCF & linked with

a food security intervention can improve child

feeding practices & nutritional status, &

4. Using locally available foods for improving

complementary feeding practices & children’s nutrition

status is a sustainable strategy, which can be

replicated by households at low cost & taken to scale

using available Government services.

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Objectives of the Research Project …

Cross-sectional nutrition baseline survey in households with children below 2 years (Aug 11; n=1041)

Restricted randomization of intervention & control villages(mean height-for-age Z-score)

Nutrition Education on complementary feeding

(Dec 12 – Jan 14)

Intervention area(12 clusters)

Cross sectional mid-term survey (Aug 13; n=921)

Food security interventions (Oct 11- Sep 12) e.g. farmer field schools,

seed & fertilizer distribution, distribution of fruit seedlings, livestock

Food security interventions

1 year

NE in group 1

& 1 m

onths in group 2; N

E m

ax 9 months

Control area(12 clusters)

Cross sectional impact survey (Aug 14; n=1221)

Longi-tudinal study

(n=124)

Focus Group discus-sions, know-ledge tests, obser-vations

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Primary outcome indicator: change in length of children

Secondary outcome indicators: achieved Minimum Dietary Diversity (MDD) among children achieved Minimum Meal Frequency (MMF) among children improved caregiver’s knowledge, attitudes & feeding, hygiene & food

safety practices

Enrolment criteria:

Caregivers with children 6-9 months at first assessment

Intervention area: member of FAO nutrition education group

Control area: resident in FAO intervention villages; matched by sex &

age in days (±14 days)

Assessments: every 3 months for one year = five assessments

Study Design

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Cross-sectional SurveysBaseline, Mid-term, & Impact

• Cross-sectional nutrition surveys in 24 EPA sections in Kasungu & Mzimba Districts

• Study population: mothers/primary caregivers and children <2 years

• Random selection of 3 villages on section (cluster) level (PPS) (baseline and mid-term)

• Random selection of 4 villages per section (PPS) (impact)

• Random selection of participants at village level

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• Baseline: August/September 2011 (sample size: height-for-age z-score)– IFSN intervention villages

• Mid-term: August/September 2013 (sample size: children’s dietary diversity)– Intervention area: nutrition education villages only (Round 1)– Control area: food security intervention villages only

• Impact: August/September 2014 (sample size: height-for-age z-score)

– Intervention area: nutrition education villages only(Round 1, same as in mid-term + 1 additional per section)

– Control area: food security intervention villages only

Cross-sectional SurveysBaseline, Mid-term, & Impact

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Study Population at Baseline, Mid-term, & ImpactBaseline (N=1041)

Aug/Sept 2011Midterm (N=921)Aug/Sept 2013

Impact (N=1221)Aug/Sept 2014

Main characteristics Int. Cont. Int. Cont. Int. Cont.

Percentage (%)

Main income source = farming 73 78 77 81 68 77

Improved drinking water source 77 76 86 83 86 83

Improved sanitation facility 27 31 59 59 50 42

Mean (SD)

HFIAS Score (min-max= 0 – 27) 6.9 ± 6.6 8.8 ± 6.9 4.4 ± 5.9 5.7 ± 6.5

Wealth index (min-max = -6.1 – 13.5) 0.4 ± 3.7 -0.1 ± 3.4 0.1 ± 3.7 -0.5 ± 3.4 0.2 ± 3.7 -0.1 ± 3.9

Years of school education of mother 5.6 ± 3.2 5.2 ± 3.1 6.3 ± 3.1 6.5 ± 2.9 7.0 ± 2.6 6.7 ± 2.9

Int.=Intervention area = food security intervention and nutrition education; Cont.=Control area = food security intervention only

Access to improved water & sanitation facilities increased over time

Food security situation improved over time, was higher in intervention area

Average years of schooling increased over time

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WHO IYCF Indicators atBaseline, Mid-term, & Impact

% children 6 to < 24 months receiving …

Baseline Aug/Sep 2011

(n = 832 )

Midterm Aug/Sep 2013

(n = 780 )

Impact Aug/Sep 2014

(n = 977)

Int. Cont. Int. Cont. Int. Cont.

Breast milk 96 93 97 98 96 95

Minimum dietary diversity 63 56 71 49 71 55

Minimum meal frequency 89 80 85 79 91 81

Minimum acceptable diet 58 48 63 43 67 48

Standardised WHO indicators (WHO 2011)Int.= intervention area = food security and nutrition educationCont. = control area = food security only

Difference-in-Differences Model

BaselineImpact

Intervention Effect

Development of control group

Hypothetical development of intervention group without intervention

Development of intervention group

Intervention

Control

Child Dietary Diversity Score (CDDS)

3.8

3.6

4.0

3.4

Baseline Impact

Covariates: age of child, maternal education, wealth

Est

imat

ed m

ean

C

DD

S

P=0.003

Intervention

Control

WHO Indicators: Complementary Feeding

CDDS significantly increased

• Intervention effect 40%, P=0.003

MDD (minimum dietary diversity) significantly increased

• Intervention effect 13%, P=0.004

MMF (minmum meal frequency) already high at baseline

MAD (minimum acceptable diet) significantly increased

• Intervention effect 12%, P=0.007

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Children Consuming ASF & Legumes a Day Before the Survey

Intervention Control Intervention Control Intervention ControlBaseline Midterm Impact

0%

20%

40%

60%

80%

Animal source foods (ASF) Legumes

P=0.001

ASF Consumption – DiD Model

12%

13%

16%

6%

Intervention

Control

Baseline Impact

Covariates: age of child, maternal education, wealth

Estim

ated

pre

vale

nce

of A

SF a

nd e

gg

cons

umpti

on 45% 45%

52%

39%

All ASF

Eggs

P=0.005

Legumes Consumption – DiD Model

67%

59%

76%

62%

Baseline Impact

Covariates: age of child, maternal education, wealth

Estim

ated

pre

vale

nce

of le

gum

es

cons

umpti

on

P=ns

Intervention

Control

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Mean (SD) height for age z-score(6-23 months old children, IMCF research area)

con

tro

l

inte

rven

tio

n

con

tro

l

inte

rven

tio

n

con

tro

l

inte

rven

tio

nBaseline 08/2011 Mid-term 08/2013 Impact 08/2014

-1.95

-1.9

-1.85

-1.8

-1.75

-1.7

-1.65

-1.6

Mea

n he

ight

for

age

z-sc

ore

(HA

Z)

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Impact on Height-for-age Z-score (DiD)Midterm Survey & Impact Survey

• Midterm Survey: Sign. differences in mean

HAZ between intervention (-0.17) & control (-

0.19) which can be related to the intervention:

food security & nutrition education

• Impact Survey: No sign. differences in mean

HAZ between intervention (-0.17) & control (-

0.18)

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Conclusions

• Food security interventions & participatory

nutrition education improved children’s

nutritional status at community level

• IFSN nutrition education approach using

local resources has a high potential to

improve dietary diversity of children

IMCF Project TeamMalawi Cambodia

Food security Project IFSN MALIS

Research Institutions Lilongwe University of Agriculture and Natural Resources (LUANAR):Dr C MasanganoDr B MtimuniDr A KalimbiraDr C Nthinda

Mahidol University & NNP Cambodia:

Dr O KevannaDr P WinichagoonDr G CharoonrukDr K Sranacharoenpong

Students Ms J KuchenbeckerMs G Chiutsi Phiriet al.

Ms A ReinbottMr M Khunet al.

FAO Headquarters Rome, Italy

Ms E Muehlhoff, Dr E Westaway, Ms T. Jeremias, Ms Graz, anduntil August 2013: Dr Gina Kennedy

JLU Giessen, Germany Prof. MB Krawinkel, MD, Dr I Jordan, Dr J Herrmann, Dr E Heil 23

Registration & Funding

German Clinical Trial Register (DRKS)https://drks-neu.uniklinik-freiburg.de/drks_web/setLocale_EN.do

The research was conducted within the IMCF Project of FAO:

http://www.fao.org/ag/humannutrition/nutritioneducation/70106/en/

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