Deanna K. Olney

Assessing impact and impact pathways of a homestead food production program on household and child nutrition in Cambodia

Background Homestead food production programs have the potential to improve maternal and child health and nutrition through multiple pathways. Objective To evaluate the impact of a homestead food production program in Cambodia on household production and consumption of micronutrient-rich foods and on maternal and child health and nutrition (intake of micronutrient-rich foods, anthropometry, hemoglobin, and anemia prevalence); and to assess pathways of impact on maternal and child health and nutrition. Methods Two cross-sectional surveys (baseline and endline) were used to assess differences between intervention (n = 300) and control (n = 200) households using t-tests and chi-square tests. Using endline data and multivariate analyses, we examined the pathways of impact of the program on maternal and child health and nutrition. Results Intervention and control households were similar at baseline in sociodemographic characteristics, but more intervention households owned animals, earned income from homestead food production, and produced and consumed micronutrient-rich foods. At endline, some of these differences had widened; more intervention households produced and consumed more vegetables, had higher dietary diversity, and had a lower prevalence of fever among children under 5 years of age. In the intervention group, more children consumed more eggs and more mothers consumed micronutrient-rich food more frequently than in the control group. There were no other differences between the groups in maternal and child health and nutrition. Greater household production of fruits and vegetables was associated with greater household dietary diversity, which was associated with dietary diversity among mothers and children. Dietary diversity was not associated with other maternal and child health and nutrition outcomes. Conclusions Cambodias homestead food production program increased household production and consumption of micronutrient-rich foods and maternal and child intake (or frequency of intake) of some of these foods. Weaknesses in the evaluation design (e.g., lack of comparability between groups at baseline, failure to control for self-selection of households into the intervention, and collection of baseline and endline data during different seasons) prevent drawing firm conclusions about the program impacts. Analysis of impact pathways also shows that household-level benefits from the program did not translate into significant improvements in maternal and child health and nutrition. A careful redesign and rigorous assessment of the program using a program theory framework would help unleash its true potential to improve maternal and child health and nutrition outcomes.

A 2-Year Integrated Agriculture and Nutrition and Health Behavior Change Communication Program Targeted to Women in Burkina Faso Reduces Anemia, Wasting, and Diarrhea in Children 3–12.9 Months of Age at Baseline: A Cluster-Randomized Controlled Trial

BACKGROUND Among young children in Burkina Faso, anemia and chronic and acute undernutrition are widespread. OBJECTIVE This study assessed the impact of Helen Keller Internationals (HKI) 2-y integrated agriculture [homestead food production (HFP)] and nutrition and health behavior change communication (BCC) program, targeted to women, on childrens (3-12.9 mo old at baseline) anthropometry (stunting, wasting, and underweight), mean hemoglobin (Hb), anemia (Hb < 11 g/dL), and diarrhea prevalence. METHODS We used a cluster-randomized controlled trial, with 55 villages randomly assigned to a control group (n = 25) or 1 of 2 treatment groups (n = 15 each), which differed by who delivered the BCC messages [older women leaders or health committee (HC) members]. We used difference-in-difference (DID) estimates to assess impacts on child outcomes. RESULTS We found marginally significant (P < 0.10) impacts on Hb (DID: 0.51 g/dL; P = 0.07) and wasting [DID: -8.8 percentage point (pp); P = 0.08] and statistically significant (P < 0.05) impacts on diarrhea (-15.9 pp; P = 0.00) in HC compared with control villages among children aged 3-12.9 mo and larger impacts for anemia (DID: -14.6 pp; P = 0.03) and mean Hb (DID: 0.74 g/dL; P = 0.03) among younger children (aged 3-5.9 mo). However, we found no significant impacts on stunting or underweight prevalence. Plausibility was supported by greater improvements in womens agricultural production and maternal infant and young child feeding and care knowledge and practices in HC compared with control villages. CONCLUSIONS HKIs 2-y integrated HFP+BCC program (HC group) significantly improved several child outcomes, including wasting (marginal), diarrhea, Hb, and anemia, especially among the youngest children. This is the first cluster-randomized controlled trial of an HFP program that documents statistically significant positive effects on these child nutrition outcomes. This trial was registered at clinicaltrials.gov as NCT01825226.

Development of nutritionally at-risk young children is predicted by malaria, anemia, and stunting in Pemba, Zanzibar.

Nutritionally at-risk children suffer delays in physical growth and motor and language development. Infectious diseases such as malaria pose an additional risk. We examined the cross-sectional relationships among malaria infection, hemoglobin (Hb) concentration, length-for-age Z-scores (LAZ), motor activity, behavior, and motor and language development in 841 Zanzibari children 5-19 mo old. We used structural equation modeling to test the fit of the data to a theoretical model and to examine the relationships among the variables in 3 age groups (5-9, 10-14, and 15-19 mo). The model fit the data for all age groups. In the youngest and oldest groups, children with higher malaria parasite densities had significantly lower Hb and LAZ. Higher LAZ significantly predicted higher total motor activity, and motor and language development scores in all age groups. In the oldest group, children who had higher Hb had higher motor development and activity scores. Malaria was directly and indirectly related to motor activity in the 10- to 14-mo-old group [standardized total effects, -0.14; direct, -0.10 (P = 0.015); and indirect, -0.038]. The significant fit of the models to the data and the statistical significance of many of the specific pathways highlight the complexities of the relationships between health and nutrition and child development outcomes in this population. In addition, the results suggest that multiple interventions are likely necessary to improve child development outcomes in this population of nutritionally at-risk children and that the potential effectiveness of interventions may differ according to age (i.e. prevention and treatment of anemia, stunting, and malaria).

Closing the gender asset gap: Learning from value chain development in Africa and Asia

This paper explores initial findings from four case studies in the Gender, Agriculture, and Assets Project on changes in gender relations in different agricultural interventions. It documents the adaptive measures projects are taking to encourage gender-equitable value chain projects. Findings suggest that the dairy and horticulture value chain cases have successfully increased the stock of both men’s and women’s tangible assets and those assets they own jointly.

The effects of iron and/or zinc supplementation on maternal reports of sleep in infants from Nepal and Zanzibar

Background: There is some evidence that sleep patterns may be affected by iron deficiency anemia but the role of iron in sleep has not been tested in a randomized iron supplementation trial. Objective: We investigated the effect of iron supplementation on maternal reports of sleep in infants in 2 randomized, placebo-controlled trials from Pemba Island, Zanzibar, and Nepal. Design: In both studies, which had parallel designs and were carried out in years 2002 to 2003, infants received iron–folic acid with or without zinc daily for 12 months, and assessments of development were made every 3 months for the duration of the study. Eight hundred seventy-seven Pemban (12.5 ± 4.0 months old) and 567 Nepali (10.8 ± 4.0 months) infants participated. Maternal reports of sleep patterns (napping frequency and duration, nighttime sleep duration, frequency of night waking) were collected. Results: Mean Hb concentration was 9.2 ± 1.1 for Pemban and 10.1 ± 1.2 g/dL for Nepali infants. Approximately, one-third of the children were stunted. Supplemental iron was consistently associated with longer night and total sleep duration. The effects of zinc supplementation also included longer sleep duration. Conclusions: Micronutrient supplementation in infants at high risk for iron deficiency and iron deficiency anemia was related to increased night sleep duration and less night waking.

Can Integrated Agriculture-Nutrition Programmes Change Gender Norms on Land and Asset Ownership? Evidence from Burkina Faso

Abstract This article uses a mixed-methods approach to analyse the impact of an integrated agriculture and nutrition programme in Burkina Faso on women’s and men’s assets, and norms regarding ownership, use and control of assets. We use a cluster-randomised controlled trial to determine whether productive asset transfers and increased income-generating opportunities for women increase women’s assets over time. Qualitative work on gender norms finds that although men still own and control most assets, women have greater decision-making power and control over home gardens and their produce, and attitudes towards women owning property have become more favourable in treatment areas.

Using Program Impact Pathways to Understand and Improve Program Delivery, Utilization, and Potential for Impact of Helen Keller International's Homestead Food Production Program in Cambodia:

Background Evidence of the impact of homestead food production programs on nutrition outcomes such as anemia and growth is scant. In the absence of information on program impact pathways, it is difficult to understand why these programs, which have been successful in increasing intake of micronutrient-rich foods, have had such limited documented impact on nutrition outcomes. Objective To conduct a process evaluation of Helen Keller Internationals (HKIs) homestead food production program in Cambodia to assess whether the program was operating as planned (in terms of design, delivery, and utilization) and to identify ways in which the program might need to be strengthened in order to increase its potential for impact. Methods A program theory framework, which laid out the primary components along the hypothesized program impact pathways, was developed in collaboration with HKI and used to design the research. Semistructured interviews and focus group discussions with program beneficiaries (n = 36 and 12, respectively), nonbeneficiaries (n = 12), and program implementers (n = 17 and 2, respectively) and observations of key program delivery points, including health and nutrition training sessions (n = 6), village model farms (n = 6), and household gardens of beneficiaries (n = 36) and nonbeneficiaries (n = 12), were conducted to assess the delivery and utilization of the primary program components along the impact pathways. Results The majority of program components were being delivered and utilized as planned. However, challenges with some of the key components posited to improve outcomes such as anemia and growth were noted. Among these were a gap in the expected pathway from poultry production to increased intake of eggs and poultry meat, and some weaknesses in the delivery of the health and nutrition training sessions and related improvements in knowledge among the village health volunteers and beneficiaries. Conclusions Although the program has been successful in delivering the majority of the program components as planned and has documented achievements in improving household production and intake of micronutrient-rich foods, it is likely that strengthening delivery and increasing utilization of some program components would increase its potential for nutritional impacts. This research has highlighted the importance of designing a program theory framework and assessing the components that lie along the primary program impact pathways to optimize program service delivery and utilization and, in turn, potential for impact.

Developmental effects of micronutrient supplementation and malaria in Zanzibari children

BACKGROUND Childrens development is affected by the interplay of internal and external factors and changes in one factor can precipitate changes in multiple developmental domains. AIMS The aim of this study was to test a theoretical model of childrens development using structural equation modeling. STUDY DESIGN This was designed as a substudy of a randomized, placebo-controlled, 2 × 2 factorial trial of the effects of daily supplementation with iron (12.5 mg) + folic acid (50 μg) (FeFA) with or without zinc (10 mg) (Zn) on child mortality. SUBJECTS Zanzibari children aged 5-9 mo (n = 106) and 10-14 mo (n = 141) at baseline were included in this sub study. OUTCOME MEASURES Longitudinal data on childrens hemoglobin, growth, malaria infection, motor development, motor activity, and language development and caregiver behavior were used to test the fit of the theoretical model for two age groups and to examine the direct and indirect relationships among the variables in the model. RESULTS The theoretical models were a good fit to the data for both age groups and revealed that FeFA with or without Zn had positive effects on motor development. FeFA alone had negative effects on language development in both age groups and Zn alone had negative effects on language development in children aged 10-14 mo. The incidence of malaria had negative effects on the majority of health and development outcomes in children aged 5-9 mo, and on motor development and hemoglobin in children aged 10-14 mo. CONCLUSIONS These findings illustrate how nutrition and health factors can affect different domains of development and how these changes can precipitate changes in other domains. More work is needed to better understand the multiple impacts of internal and external factors on childrens development and how changes in developmental domains interact with each other over time to determine childrens overall developmental trajectory. The randomized, placebo-controlled study was registered as an International Standard Randomized Controlled Trial, number ISRCTN59549825.

Tubaramure, a Food-Assisted Integrated Health and Nutrition Program in Burundi, Increases Maternal and Child Hemoglobin Concentrations and Reduces Anemia: A Theory-Based Cluster-Randomized Controlled Intervention Trial

BACKGROUND Despite their popularity, food-assisted maternal and child health and nutrition (MCHN) programs have not been evaluated rigorously, and evidence of their impacts on maternal and child outcomes is scant. OBJECTIVE This study estimated the impact of Tubaramure, a food-assisted MCHN program implemented by Catholic Relief Services and partners in eastern Burundi, on hemoglobin and anemia (primary outcome) in children aged 0-23.9 mo and their mothers and explored the impact pathways. The program targeted women and their children during their first 1000 d of life and included 1) food rations, 2) strengthening and promotion of the use of health services, and 3) behavior change communication. METHODS This was a cluster-randomized controlled study to assess program impact by using cluster fixed-effects double-difference models with repeated cross-sectional data (baseline and follow-up 2 y later). We explored impact pathways by estimating impact on intermediary factors addressed by Tubaramure that are known determinants of hemoglobin and anemia and by regressing hemoglobin and anemia on each determinant to assess the plausibility that the effect operated through each determinant. RESULTS Hemoglobin decreased and anemia increased markedly from baseline to follow-up, but Tubaramure had a significant (P < 0.05) beneficial effect on both children [6.1 percentage points (pps)] and mothers who had given birth in the previous 3 mo (34.9 pps). The program also had significant (P < 0.05) impacts on factors along the hypothesized impact pathways: dietary diversity, consumption of iron-rich foods, morbidity, and fever for child hemoglobin and dietary diversity, consumption of iron-rich foods, and current bed-net use for maternal anemia. CONCLUSIONS We showed, for the first time to our knowledge, that a food-assisted MCHN program had a positive impact on anemia and hemoglobin in both mothers and children. The plausible pathways identified highlight the importance of addressing multiple determinants of anemia. This trial was registered at clinicaltrials.gov as NCT01072279.

PROCOMIDA, a Food-Assisted Maternal and Child Health and Nutrition Program, Reduces Child Stunting in Guatemala: A Cluster-Randomized Controlled Intervention Trial

Abstract Background Food-assisted maternal and child health and nutrition (FA-MCHN) programs may foster child growth during the first 1000 d (pregnancy and the first 2 y of a childs life), but evidence is scant. Objective We evaluated the impact of an FA-MCHN program, PROCOMIDA, on linear growth (stunting [length-for-age z score (LAZ) < –2] and length-for-age difference [LAD]) among children aged 1–24 mo. PROCOMIDA was implemented in Guatemala by Mercy Corps and was available to beneficiaries throughout the first 1000 d. Methods We used a longitudinal, cluster-randomized controlled trial with groups varying in family ration sizes [full (FFR), reduced (RFR), and none (NFR)] and individual ration types provided to mothers (pregnancy to 6 mo postpartum) and children (6–24 mo of age) [corn-soy blend (CSB), lipid-based nutrient supplement (LNS), micronutrient powder (MNP)]: 1) FFR + CSB (n = 576); 2) RFR + CSB (n = 575); 3) NFR + CSB (n = 542); 4) FFR + LNS (n = 550); 5) FFR + MNP (n = 587); 6) control (n = 574). Program impacts compared with control, and differential impacts between groups varying family ration size or individual ration type, were assessed through the use of linear mixed-effects models and post hoc simple effect tests (significant if P < 0.05). Results PROCOMIDA significantly reduced stunting at age 1 mo in FFR + CSB, RFR + CSB, and FFR + MNP groups compared with control [5.05, 4.06, and 3.82 percentage points (pp), respectively]. Stunting impact increased by age 24 mo in FFR + CSB and FFR + MNP relative to control (impact = 11.1 and 6.5 pp at age 24 mo, respectively). For CSB recipients, the FFR compared with RFR or NFR significantly reduced stunting (6.47–9.68 pp). CSB reduced stunting significantly more than LNS at age 24 mo (8.12 pp). Conclusions FA-MCHN programs can reduce stunting during the first 1000 d, even in relatively energy/food-secure populations. Large family rations with individual rations of CSB or MNP were most effective. The widening of impact as children age highlights the importance of intervening throughout the full first 1000 d. This trial was registered at clinicaltrials.gov as NCT01072279.