Dataset Information

Community-Based Interventions to Reduce Child Stunting in Rural Guatemala: A Quality Improvement Model.

ABSTRACT: Rural Guatemala has one of the highest rates of chronic child malnutrition (stunting) in the world, with little progress despite considerable efforts to scale up evidence-based nutrition interventions. Recent literature suggests that one factor limiting impact is inadequate supervisory support for frontline workers. Here we describe a community-based quality improvement intervention in a region with a high rate of stunting. The intervention provided audit and feedback support to frontline nutrition workers through electronic worklists, performance dashboards, and one-on-one feedback sessions. We visualized performance indicators and child nutrition outcomes during the improvement intervention using run charts and control charts. In this small community-based sample (125 households at program initiation), over the two-year improvement period, there were marked improvements in the delivery of program components, such as growth monitoring services and micronutrient supplements. The prevalence of child stunting fell from 42.4 to 30.6%, meeting criteria for special cause variation. The mean length/height-for-age Z-score rose from -1.77 to -1.47, also meeting criteria for special cause variation. In conclusion, the addition of structured performance visualization and audit and feedback components to an existing community-based nutrition program improved child health indicators significantly through improving the fidelity of an existing evidence-based nutrition package.

SUBMITTER: Juarez M

PROVIDER: S-EPMC7831302 | biostudies-literature | 2021 Jan

REPOSITORIES: biostudies-literature

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Community-Based Interventions to Reduce Child Stunting in Rural Guatemala: A Quality Improvement Model.

Juarez Michel M Dionicio Carlos C Sacuj Neftali N Lopez Waleska W Miller Ann C AC Rohloff Peter P

International journal of environmental research and public health 20210118 2

Rural Guatemala has one of the highest rates of chronic child malnutrition (stunting) in the world, with little progress despite considerable efforts to scale up evidence-based nutrition interventions. Recent literature suggests that one factor limiting impact is inadequate supervisory support for frontline workers. Here we describe a community-based quality improvement intervention in a region with a high rate of stunting. The intervention provided audit and feedback support to frontline nutrit ...[more]

PMID: 33477580

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Project description:BackgroundAppropriate infant and young child feeding practices are critical for optimal child growth and development, but in Ethiopia, complementary feeding (CF) practices are very poor. Alive & Thrive (A&T) provided intensive behavior change interventions through 4 platforms: interpersonal communication (IPC), nutrition-sensitive agricultural activities (AG), community mobilization (CM), and mass media (MM).ObjectivesThe aim of this study was to evaluate the impact of A&T intensive compared with nonintensive interventions (standard nutrition counseling and agricultural extension service and less intensive CM and MM) on CF practices and knowledge and child anthropometric outcomes.MethodsWe used a cluster-randomized evaluation design with cross-sectional surveys among households with children aged 6-23.9 mo [n = 2646 at baseline (2015) and n = 2720 at endline (2017)]. We derived difference-in-difference impact estimates (DDEs) and conducted dose-response and path analyses to document plausibility of impacts.ResultsAt endline, exposure to IPC was 17.8-32.3%, exposure to AG was 22.7-36.0%, exposure to CM was 18.6-54.3%, and exposure to MM was 35.4% in the intensive group. Minimum dietary diversity and minimum acceptable diet increased significantly in the intensive group but remained low at endline (24.9% and 18.2%, respectively). Significant differential declines in stunting prevalence were observed (DDE: -5.6 percentage points; P < 0.05) in children aged 6-23.9 mo, decreasing from 36.3% to 22.8% in the intensive group. Dose-response analyses showed higher odds of minimum dietary diversity (OR: 3.3; 95% CI: 2.2, 4.8) and minimum meal frequency (OR: 1.9; 95% CI: 1.4, 2.6) and higher height-for-age z score (HAZ) (β: 0.24; 95% CI: 0.04, 0.4) among women exposed to 3 or 4 platforms. Path analyses showed a strong relation between AG and egg consumption, which led to increased child dietary diversity and HAZ.ConclusionsDelivery of social and behavior change interventions using multiple platforms was feasible and effective, resulting in improvements in CF practices and child stunting within a 2-y period. There is a need for continued efforts, however, to expand intervention coverage and to improve CF practices in Ethiopia. This trial was registered at clinicaltrials.gov as NCT02775552.

Project description:BackgroundChild health indicators have substantially improved across the last decade, yet Afghanistan has among the highest child stunting and malnutrition rates in Asia. Multisectoral approaches were recently introduced but evidence for this approach to improve support for and implementation of child nutrition programmes is limited compared to other countries.MethodsWe reviewed policy and programme data to identify best practices and gaps surrounding child malnutrition in Afghanistan. We conducted a scoping review using broad search categories and approaches, including database and website searches, reference hand-searches, purposive policy and programme document request, and key informant interviews. Inclusion and exclusion criteria were developed iteratively, with abstracts and documents assessed against the final criteria. We abstracted documents systematically and summarised and synthesised content to generate the main findings.ResultsWe included 18 policies and strategies, 45 data sources and reports, and 20 intervention evaluations. Movement towards multisectoral efforts to address malnutrition at the policy level has started; however, integrated nutrition-specific and nutrition-sensitive interventions are not yet uniformly delivered at the community level. Many data sources capturing nutrition, food security and WASH (water, sanitation and hygiene) indicators are available but indicator definitions are not standardised and there are few longitudinal nutrition surveys. Political will to improve household nutrition status has shown increased government and donor investments in nutrition-sensitive and nutrition-specific programmes through combined small- and large-scale interventions between 2004 and 2013; however, evidence for interventions that effectively decrease stunting prevalence is limited.ConclusionsThis review shows a breadth of nutrition programme, policy and data in Afghanistan. Multisector approaches faced challenges of reaching sufficient coverage as they often included a package of food security, livelihoods and health interventions but were each implemented independently. Further implementation evidence is needed to aid policy and programmes on effective integration of nutrition, food security and WASH in Afghanistan.

Project description:Abstract Objectives To determine the long-term impact of a micronutrient fortified supplement on stunting rates and micronutrient status in young children living in rural Guatemala, which has the highest stunting prevalence in Latin America. Methods A parallel, open label randomised control trial in rural children aged 6–72 months (Registration NCT01643187). After growth screening, all children < 1SD for either weight for height (WHZ), height for age (HAZ), or weight for age (WAZ) were randomly allocated using 7:3 ratio, stratified by locality and age to receive either the test drink, Chispuditos®, a corn/soy beverage fortified with 21 vitamins or de-lactosed milk (control). Both drinks were isoproteic (4g/drink) and had similar energy content (test drink 147 kcal, milk 117 kcal) but the tst drink had higher micronutrient content (e.g., 9 mg zinc, 12.5 mg iron vs 1.5 mg zinc, 1.9 mg iron in control). They were supplied for 18 months and monthly visits were conducted to test for adherence. Results A total of 1238 children were screened, 971 met the criteria and 681 were allocated to test drink and 290 to control. At baseline, malnutrition prevalence of stunting (HAZ < -2SD), for test vs control was 48.4% vs 47.9%, 5.5% vs 6.7% for wasting (WHZ < -2SD) and 19.9% vs 18.7% for underweight (WAZ < -2SD). 73% of children reported to consume at least half of allocated drinks/day. After 18 months of intervention, the prevalence and relative risks [RR (95% CI)] for stunting in the test: control were 40.6:40.7% [RR 0.99 (0.84, 1.19)]; similarly, no differences were seen in WAZ, WHZ nor micronutrient status. Conclusions In this trial in rural Guatemalan children, long term supplementation with a micronutrient enriched drink had no impact on either stunting or micronutrient status. These results differ form long-term studies in urban Guatemalan nurseries. The present study suggest that fortified foods alone are not enough to reduce stunting rates in this setting when fed during an 18 month period. Funding Sources The Mathile Institute for the Advancement of Human Nutrition funded this study.

Project description:BackgroundChild stunting and linear growth faltering have declined over the past few decades and several countries have made exemplary progress.ObjectivesTo synthesize findings from mixed methods studies of exemplar countries to provide guidance on how to accelerate reduction in child stunting.MethodsWe did a qualitative and quantitative synthesis of findings from existing literature and 5 exemplar country studies (Nepal, Ethiopia, Peru, Kyrgyz Republic, Senegal). Methodology included 4 broad research activities: 1) a series of descriptive analyses of cross-sectional data from demographic and health surveys and multiple indicator cluster surveys; 2) multivariable analysis of quantitative drivers of change in linear growth; 3) interviews and focus groups with national experts and community stakeholders and mothers; and 4) a review of policy and program evolution related to nutrition.ResultsSeveral countries have dramatically reduced child stunting prevalence, with or without closing geographical, economic, and other population inequalities. Countries made progress through interventions from within and outside the health sector, and despite significant heterogeneity and differences in context, contributions were comparable from health and nutrition sectors (40% of change) and other sectors (50%), previously called nutrition-specific and -sensitive strategies. Improvements in maternal education, maternal nutrition, maternal and newborn care, and reductions in fertility/reduced interpregnancy intervals were strong contributors to change. A roadmap to reducing child stunting at scale includes several steps related to diagnostics, stakeholder consultations, and implementing direct and indirect nutrition interventions related to the health sector and nonhealth sector .ConclusionsOur results show that child stunting reduction is possible even in diverse and challenging contexts. We propose that our framework of organizing nutrition interventions as direct/indirect and inside/outside the health sector should be considered when mapping causal pathways of child stunting and planning interventions and strategies to accelerate stunting reduction to achieve the 2030 Sustainable Development Goals.

Project description:BackgroundFood-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 child's life), but evidence is scant.ObjectiveWe 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.MethodsWe 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).ResultsPROCOMIDA 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).ConclusionsFA-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.

Project description:IntroductionEver since the 1960s, Guatemala has been a principle site for global academic research on child growth and nutrition. Nevertheless, Guatemala still has one of the highest rates of child stunting in the world. Since 2012, Guatemala has had a comprehensive national policy on stunting, calling for a renewed investment in innovative, multilevel nutrition interventions and implementation science. Our objective was to perform a systematic search and scoping review of the literature on stunting in Guatemala to identify gaps in research and opportunities for responding to this unique policy opportunity.MethodsWe conducted a systematic search and scoping review on stunting in Guatemala, searching the PubMed, Web of Science and PsycINFO databases. Eligible articles were of any design or format, published in English and Spanish from 2000 to 2018. Articles were thematically grouped by those published before (2000-2011) and after (2012-2018) the new national policy initiatives.ResultsWe identified a total of 1934 articles through database searches. After full-text review, 104 were included in the synthesis. The volume of published articles on stunting increased from a mean of 3.2 to 9.4 articles/year before and after 2012. There was a shift toward articles generating new data on priority populations, including rural indigenous Maya populations (34% vs 61%, χ2 test, p=0.01). However, the proportion of studies conducting implementation evaluations or testing new interventions was low and did not change significantly (34% vs 18%, χ2 test, p=0.07). Among 17 identified intervention studies, only 4 tested multilevel interventions, and there were no published interventions incorporating nutrition-sensitive interventions.ConclusionsA systematic search and scoping review of the literature on child stunting in Guatemala identified critical opportunities for new research in multilevel interventions, nutrition-sensitive interventions and implementation science.

Project description:BackgroundChild stunting is a critical global health issue. Guatemala has one of the world's highest levels of stunting despite the sustained commitment to international nutrition policy best practices endorsed by the Scaling Up Nutrition (SUN) movement. Our objective was to use Guatemala as a case study to project the impact of a recently published national nutrition policy, the Great Crusade, that is consistent with SUN principles.MethodsWe used the Lives Saved Tool (LiST) to project the impact of scaling-up of nutrition interventions proposed in the Great Crusade and recommended by SUN. Our outcomes were changes in stunting prevalence, number of stunting cases averted, and number of cases averted by intervention in children under 5 years of age from 2020 to 2030. We considered 4 scenarios: (1) intervention coverage continues based on historical trends, (2) coverage targets in the Great Crusade are achieved, (3) coverage targets in the Great Crusade are achieved with reduced fertility risk, and (4) coverage reaches an aspirational level.ResultsAll scenarios led to modest reductions in stunting prevalence. In 2024, stunting prevalence was estimated to change by -0.1% (95% confidence interval [CI]= 0.0%,-0.2%) if historical trends continue, -1.1% (95% CI=-0.8%,-1.5%) in the Great Crusade scenario, and -2.2% (95% CI=-1.6%,-3.0%) in the aspirational scenario. In 2030, we projected a stunting prevalence of -0.4% (95% CI=-0.2%,-0.8%) and -3.7% (95% CI=-2.8%,-5.1%) in the historical trends and aspirational scenario, respectively. Complementary feeding, sanitation, and breastfeeding were the highest-impact interventions across models.ConclusionsTargeted reductions in child stunting prevalence in Guatemala are unlikely to be achieved solely based on increases in intervention coverage. Our results show the limitations of current paradigms recommended by the international nutrition community. Policies and strategies are needed to address the broader structural drivers of stunting.

Dataset Information

Community-Based Interventions to Reduce Child Stunting in Rural Guatemala: A Quality Improvement Model.

Publications

Community-Based Interventions to Reduce Child Stunting in Rural Guatemala: A Quality Improvement Model.

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