Helena Pachón

Work outside the home is the primary barrier to exclusive breastfeeding in rural Viet Nam: insights from mothers who exclusively breastfed and worked

This study assessed barriers to exclusive breastfeeding in rural Viet Nam and identified how a few mothers were able to exclusively breastfeed despite barriers. A cross-sectional quantitative and qualitative assessment was carried out among 120 mothers of infants less than six months old in northern Viet Nam. Only 24% of the mothers exclusively breastfed. Adjusting for infants age and who attended delivery, the risk of not exclusively breastfeeding was 14.0 times greater for women who had returned to work than for women who had not. Exclusively breastfeeding mothers (n = 4) who worked differed from other mothers in important ways. They all felt they had enough milk, all knew the appropriate time to introduce foods and liquids, and most were supported in their breastfeeding decisions by commune health workers and family members. This research suggests strategies that can be implemented now to increase exclusive breastfeeding in rural work environments. These include improving knowledge about the introduction of water and semi-solids, addressing perceptions of milk insufficiency, securing support from others, and presenting mothers with options for exclusively breastfeeding, even when they work outside the home.

Caregiver Styles of Feeding and Child Acceptance of Food in Rural Viet Nam

Style of child feeding may be an important determinant of child nutrition and health outcomes. Responsive feeding refers to the level and kind of interaction between caregiver and child that lead to a positive feeding experience, adequate dietary intake, and enhanced developmental opportunities. Responsive feeding behaviors may include active physical help and verbalization during feeding, role-playing, persistence, and positive feeding strategies. The aim of this study was to investigate styles of feeding among Vietnamese children 12 or 18 months of age from a rural province in northern Viet Nam. Forty child/mother pairs were videotaped during two, two-hour feeding episodes. Caregiver and child behaviors were coded at the level of the “intended bite” as observed through the videotape analysis of feeding episodes to assess caregiver behavior and the childs interest and acceptance of food. We found it feasible to use videotape and the modified coding and analysis scheme, originally developed for work in Peru, in Viet Nam. In Viet Nam, caregivers provided physical help to eat nearly all of the time in the younger children, and about 70% of the time among 18 month olds. Caregivers verbalized during only 30% of intended bites, and only half of these verbalizations were responsive in tone or words. Positive caregiver behaviors were significantly associated with higher childs acceptance of food, while non-responsive feeding behaviors were associated with child rejection of food. Future analyses of this data set will evaluate the degree to which an integrated nutrition program positively modified caretaker behaviors. More research is needed to demonstrate the relationships among the promotion of responsive feeding behaviors, acceptance of food, and improved nutrition and health status of children.

An Integrated Child Nutrition Intervention Improved Growth of Younger, More Malnourished Children in Northern Viet Nam

Integrated nutrition programs are widely used to prevent and/or reverse childhood malnutrition, but rarely rigorously evaluated. The impact of such a program on the physical growth of young rural Vietnamese children was measured. We randomized six communes to receive an integrated nutrition program implemented by Save the Children. We matched six communes to serve as controls. Our sample consisted of 238 children (n = 119 per group) who were 5 to 30 months old on entry. Between December 1999 and December 2000, we measured weight and height monthly for six months and again at month 12. Principle outcomes were weight-for-age Z score (WAZ), height-for-age Z score (HAZ), and weight-for-height Z score (WHZ), and the changes among these measures. As expected, anthropometric indicators relative to international references worsened as the children aged. Overall, children in the intervention communes who were exposed to the integrated nutrition program did not show statistically significant better growth than comparison children. Intervention children who were younger (15 months or less) and more malnourished (less than −2 Z) at baseline, however, deteriorated significantly less than their comparable counterparts. Between baseline and month four, for example, intervention children who were malnourished and less than 15 months old at entry lost on average 0.05 WAZ while similar comparison children lost 0.25 WAZ (p = .02). Lack of overall impact on growth may be due to a lower than expected prevalence of malnutrition at baseline and/or deworming of comparison children. Targeting nutrition interventions at very young children will have the maximum impact on growth.

Design of a prospective, randomized evaluation of an integrated nutrition program in rural Viet Nam.

Few prospective studies of child growth and its determinants take place in programmatic contexts. We evaluated the effect of Save the Childrens (SC) community empowerment and nutrition program (CENP) on child growth, care, morbidity, empowerment, and behavioral determinants. This paper describes the research methods of this community-based study. We used a longitudinal, prospective, randomized design. We selected 12 impoverished communes with documented child malnutrition, three comparison, and three intervention communes in each of two districts in Phu Tho Province, west of Hanoi. SC taught district trainers in November 1999 to train local health volunteers to implement the 10-month CENP, including situation analysis, positive deviance (PD) inquiry, growth monitoring and promotion, nutrition education and rehabilitation program (NERP), deworming, and monitoring. PD inquiries aim to discover successful care practices in poor households that likely promote well-nourished children. NERPs are neighborhood-based, facilitated group learning sessions where caregivers of malnourished children learn and practice PD and other healthy behaviors. We dewormed all intervention and comparison children. We weighed all children less than 24 months of age living in the intervention and comparison communes and randomly selected 240 children (120 intervention and 120 comparison). We gathered information on nutritional status, diet, illness, care, behavioral determinants, empowerment, and program quality, monthly for six months with a re-survey at 12 months. We collected most information through maternal interview but also observed hygiene and program quality, and videotaped feedings at home. Some implementation and research limitations will attenuate CENP impact and measurement of its effectiveness.

Household Food Insecurity Is Associated with Childhood Malaria in Rural Haiti

Haiti is the poorest country in the Western Hemisphere and is heavily affected by food insecurity and malaria. To find out if these 2 conditions are associated with each other, we studied a convenience sample of 153 women with children 1-5 y old in Camp Perrin, South Haiti. Household food insecurity was assessed with the 16-item Escala Latinoamericana y Caribeña de Seguridad Alimentaria (ELCSA) scale previously validated in the target communities. ELCSAs reference time period was the 3 mo preceding the survey and it was answered by the mother. Households were categorized as either food secure (2%; ELCSA score = 0), food insecure/very food insecure (42.7%; ELCSA score range: 1-10), or severely food insecure (57.3%; ELCSA score range: 11-16). A total of 34.0% of women reported that their children had malaria during the 2 mo preceding the survey. Multivariate analyses showed that severe food insecure was a risk factor for perceived clinical malaria (odds ratio: 5.97; 95% CI: 2.06-17.28). Additional risk factors for perceived clinical malaria were as follows: not receiving colostrum, poor child health (via maternal self-report), a child BMI <17 kg/m(2), and child vitamin A supplementation more than once since birth. Findings suggest that policies and programs that address food insecurity are also likely to reduce the risk of malaria in Haiti.

Designing appropriate complementary feeding recommendations: tools for programmatic action

Suboptimal complementary feeding practices contribute to a rapid increase in the prevalence of stunting in young children from age 6 months. The design of effective programmes to improve infant and young child feeding requires a sound understanding of the local situation and a systematic process for prioritizing interventions, integrating them into existing delivery platforms and monitoring their implementation and impact. The identification of adequate food-based feeding recommendations that respect locally available foods and address gaps in nutrient availability is particularly challenging. We describe two tools that are now available to strengthen infant and young child-feeding programming at national and subnational levels. ProPAN is a set of research tools that guide users through a step-by-step process for identifying problems related to young child nutrition; defining the context in which these problems occur; formulating, testing, and selecting behaviour-change recommendations and nutritional recipes; developing the interventions to promote them; and designing a monitoring and evaluation system to measure progress towards intervention goals. Optifood is a computer-based platform based on linear programming analysis to develop nutrient-adequate feeding recommendations at lowest cost, based on locally available foods with the addition of fortified products or supplements when needed, or best recommendations when the latter are not available. The tools complement each other and a case study from Peru illustrates how they have been used. The readiness of both instruments will enable partners to invest in capacity development for their use in countries and strengthen programmes to address infant and young child feeding and prevent malnutrition.

Why Does Nutrition Deteriorate Rapidly among Children under 2 Years of Age? Using Qualitative Methods to Understand Community Perspectives on Complementary Feeding Practices in Bangladesh

Background Child undernutrition remains high in South Asian and sub-Saharan African countries. Rapid declines in nutritional status occur before the age of 2 years, particularly during the period of complementary feeding. Improving complementary feeding practices is a neglected area in nutrition programs. Objective To understand community perspectives on complementary feeding practices in order to inform the design of future interventions for improved complementary feeding. Methods From May through August 2009, data were collected in two rural locations and one urban location in Bangladesh through semistructured interviews, food attributes exercises, 24-hour dietary recalls, opportunistic observations, and trials of improved practices (TIPs). Key informant interviews and focus group discussions were also carried out among family members and community opinion leaders. Results Lay perceptions about complementary feeding differ substantially from international complementary feeding recommendations. A large proportion of children do not consume sufficient amounts of complementary foods to meet their energy and micronutrient needs. There was a gap in knowledge about appropriate complementary foods in terms of quality and quantity and strategies to convert family foods to make them suitable for children. Complementary feeding advice from family members, peers, and health workers, the importance given to feeding young children, and time spent by caregivers in feeding influenced the timing, frequency, types of food given, and ways in which complementary feeding occurred. Conclusions Perceptions and practices related to complementary feeding need to be effectively addressed to improve the levels of child undernutrition. Lack of understanding of childrens nutritional needs and insufficient time for feeding children are key barriers to complementary feeding.

Effect of an integrated nutrition program on child morbidity due to respiratory infection and diarrhea in northern Viet Nam

Infectious disease and poor diet are the two proximal causes of malnutrition in children. During the 1990s, integrated nutrition programs implemented by Save the Children (SC) in Vietnam reduced severe child malnutrition, but it has not been clear if this impact was due primarily to improved diet or reduced disease. The aim of this study was to determine whether a community-based, integrated nutrition program in Vietnam reduced child morbidity due to diarrhea or acute respiratory infections. Children 5 to 25 months old were randomly selected from randomly assigned intervention and comparison communes. Caregivers of children from the intervention and comparison groups (n = 119 per group) were interviewed about their childs morbidity at program baseline and at study months 2, 4, 6, and 12. Multiple logistic regression and general estimating equations (GEE) were used to evaluate the effect of the intervention on the occurrence of any diarrhea and respiratory illness in the preceding two weeks. Respiratory illness, mainly upper respiratory illness, was more common than diarrheal disease at baseline (54% vs. 6%, respectively). During follow-up, children in the intervention communes had approximately half the respiratory illness experienced by those in comparison communes (AOR = 0.5; p = .001). Diarrheal disease was also lower in the intervention group, although differences were not statistically significant. We conclude that SCs integrated nutrition program was associated with reduced upper respiratory illness, perhaps due to improved hygiene practices and/or improved micronutrient intakes.

A 2015 global update on folic acid-preventable spina bifida and anencephaly.

BACKGROUND Spina bifida and anencephaly are two major neural tube defects. They contribute substantially to perinatal, neonatal, infant, and under-five mortality and life-long disability. To monitor the progress toward the total prevention of folic acid-preventable spina bifida and anencephaly (FAP SBA), we examined their global status in 2015. METHODS Based on existing data, we modeled the proportion of FAP SBA that are prevented in the year 2015 through mandatory folic acid fortification globally. We included only those countries with mandatory fortification that added at least 1.0 ppm folic acid as a fortificant to wheat and maize flour, and had complete information on coverage. Our model assumed mandatory folic acid fortification at 200 μg/day is fully protective against FAP SBA, and reduces the rate of spina bifida and anencephaly to a minimum of 0.5 per 1000 births. RESULTS Our estimates show that, in 2015, 13.2% (35,500 of approximately 268,700 global cases) of FAP SBA were prevented in 58 countries through mandatory folic acid fortification of wheat and maize flour. Most countries in Europe, Africa, and Asia were not implementing mandatory fortification with folic acid. CONCLUSION Knowledge that folic acid prevents spina bifida and anencephaly has existed for 25 years, yet only a small fraction of FAP SBA is being prevented worldwide. Several countries still have 5- to 20-fold epidemics of FAP SBA. Implementation of mandatory fortification with folic acid offers governments a proven and rapid way to prevent FAP SBA-associated disability and mortality, and to help achieve health-related Sustainable Development Goals. Birth Defects Research (Part A) 106:520-529, 2016.

What influences health behavior? Learning from caregivers of young children in Viet Nam

Globally, the caregiving behaviors that contribute to good nutritional status are well understood; but it is not clear why some caregivers perform these behaviors while others do not. This formative qualitative research was designed to improve understanding about what distinguishes caregivers who practice optimal behaviors from those who do not. This study is a one-time, cross-sectional baseline assessment of factors that affect nutrition-related behavior change. It took place in a rural northern province in Viet Nam. One hundred caregivers of children 6 to 17.9 months of age from five communes were interviewed. None of the five communes were included in the larger prospective study designed to test the impact of the community empowerment and nutrition program (CENP). Four behaviors were examined: feeding the child “positive deviant” foods, feeding the child during diarrheal episodes, washing the childs hands, and taking the child to the health center when ill. Results indicate that for all four behaviors, favorable social norms distinguished those who practiced each behavior from those who did not. Positive, reinforcing beliefs and attitudes were important determinants of every behavior except handwashing. Likewise, self-efficacy differentiated doers from non-doers for all behaviors except feeding during diarrheal episodes. Findings from this research suggest that fathers and in-laws of non-doers are more likely to fail to advise mothers about infant feeding and health than they are to provide negative advice. By discovering what distinguishes those who practice optimal behaviors from those who do not, researchers, program planners, and others are better equipped to develop targeted interventions that lead to positive behavior change.