A Multisectoral Nutrition Program in Nepal Improves Knowledge of Dietary Diversity, Sick Child Feeding, and Handwashing, but Not All Practices: a Program Impact Pathways Mediation Analysis

Overview

Journal Curr Dev Nutr

Specialty Nutritional Sciences

Date 2020 Apr 8

PMID 32258988

Authors

Jowel Choufani

Zeina Jamaluddine

Kenda Cunningham

Affiliations

Soon will be listed here.

Abstract

Background: Few intervention studies have focused on how inputs link with outcomes.

Objectives: This study tested whether Suaahara I program inputs translated into intended outcomes and identified gaps along the theorized program impact pathway to improved nutrition, care, and water, sanitation, and hygiene behaviors.

Methods: We used household-level, cross-sectional survey data from a process evaluation of Suaahara I conducted in 2014. A total of 480 households with a pregnant woman or child aged <2 y were selected with an equal split between intervention and comparison arms. We used regression models to test associations between exposure to Suaahara I and 3 primary outcomes and 3 parallel knowledge mediators: child minimum dietary diversity, child feeding during illness, and proper handwashing during child care. We used generalized structural equation modeling using full information maximum likelihood to test whether knowledge mediated associations between exposure and outcomes.

Results: In the adjusted regression models between maternal exposure to Suaahara I and 3 behavioral outcomes, we found a small positive association for handwashing (β: 0.21; 95% CI: 0.10, 0.31), but no association with the other 2 outcomes. In the mediation analysis, maternal exposure to Suaahara I, however, was associated with the mediator (knowledge) for all 3 outcomes: handwashing with soap and water (β: 0.05 ± 0.02), child minimum dietary diversity (logit = 0.06; P = 0.03), and child feeding during illness (logit = 0.09 ± 0.02). We found a positive, significant association for the full indirect pathway of program input to output via knowledge for child feeding during illness (logit = 0.07 ± 0.03) only.

Conclusions: Exposure to Suaahara I behavior change interventions improved knowledge, but this did not always translate into improved practices. It is important to address barriers to optimal practices beyond knowledge in future nutrition programs in Nepal.

References

Ruel M, Alderman H . Nutrition-sensitive interventions and programmes: how can they help to accelerate progress in improving maternal and child nutrition?. Lancet. 2013; 382(9891):536-51. DOI: 10.1016/S0140-6736(13)60843-0. View

Diaz T, Guenther T, Oliphant N, Muniz M . A proposed model to conduct process and outcome evaluations and implementation research of child health programs in Africa using integrated community case management as an example. J Glob Health. 2014; 4(2):020409. PMC: 4267085. DOI: 10.7189/jogh.04.020409. View

Wolf E, Harrington K, Clark S, Miller M . Sample Size Requirements for Structural Equation Models: An Evaluation of Power, Bias, and Solution Propriety. Educ Psychol Meas. 2015; 76(6):913-934. PMC: 4334479. DOI: 10.1177/0013164413495237. View

Olney D, Kariger P, Stoltzfus R, Khalfan S, Ali N, Tielsch J . Developmental effects of micronutrient supplementation and malaria in Zanzibari children. Early Hum Dev. 2013; 89(9):667-74. DOI: 10.1016/j.earlhumdev.2013.04.013. View

Cunningham K, Singh A, Rana P, Brye L, Alayon S, Lapping K . Suaahara in Nepal: An at-scale, multi-sectoral nutrition program influences knowledge and practices while enhancing equity. Matern Child Nutr. 2017; 13(4). PMC: 6866152. DOI: 10.1111/mcn.12415. View

Singh A, Singh A, Ram F . Household food insecurity and nutritional status of children and women in Nepal. Food Nutr Bull. 2014; 35(1):3-11. DOI: 10.1177/156482651403500101. View

Olney D, Kariger P, Stoltzfus R, Khalfan S, Ali N, Tielsch J . Development of nutritionally at-risk young children is predicted by malaria, anemia, and stunting in Pemba, Zanzibar. J Nutr. 2009; 139(4):763-72. DOI: 10.3945/jn.107.086231. View

VanderWeele T . Invited commentary: structural equation models and epidemiologic analysis. Am J Epidemiol. 2012; 176(7):608-12. PMC: 3530375. DOI: 10.1093/aje/kws213. View

Affleck W, Pelto G . Caregivers' responses to an intervention to improve young child feeding behaviors in rural Bangladesh: a mixed method study of the facilitators and barriers to change. Soc Sci Med. 2012; 75(4):651-8. DOI: 10.1016/j.socscimed.2012.03.030. View

10.

Kim S, Ali D, Kennedy A, Tesfaye R, Tadesse A, Abrha T . Assessing implementation fidelity of a community-based infant and young child feeding intervention in Ethiopia identifies delivery challenges that limit reach to communities: a mixed-method process evaluation study. BMC Public Health. 2015; 15:316. PMC: 4392481. DOI: 10.1186/s12889-015-1650-4. View

11.

Pham J, Pelletier D . Action-Oriented Population Nutrition Research: High Demand but Limited Supply. Glob Health Sci Pract. 2015; 3(2):287-99. PMC: 4476865. DOI: 10.9745/GHSP-D-15-00009. View

12.

Factor-Litvak P, Sher A . Invited commentary: coming out of the box. Am J Epidemiol. 2009; 169(10):1179-81. DOI: 10.1093/aje/kwp066. View

13.

Robert R, Gittelsohn J, Creed-Kanashiro H, Penny M, Caulfield L, Narro M . Process evaluation determines the pathway of success for a health center-delivered, nutrition education intervention for infants in Trujillo, Peru. J Nutr. 2006; 136(3):634-41. DOI: 10.1093/jn/136.3.634. View

14.

Gillespie S, Menon P, Kennedy A . Scaling up impact on nutrition: what will it take?. Adv Nutr. 2015; 6(4):440-51. PMC: 4496740. DOI: 10.3945/an.115.008276. View

15.

Bonvecchio A, Pelto G, Escalante E, Monterrubio E, Habicht J, Nava F . Maternal knowledge and use of a micronutrient supplement was improved with a programmatically feasible intervention in Mexico. J Nutr. 2007; 137(2):440-6. DOI: 10.1093/jn/137.2.440. View

16.

Skrabanek P . The emptiness of the black box. Epidemiology. 1994; 5(5):553-5. View

17.

Newman J, Garces A, Mazariegos M, Hambidge K, Manasyan A, Tshefu A . Theory-driven process evaluation of a complementary feeding trial in four countries. Health Educ Res. 2014; 29(2):297-305. PMC: 3959202. DOI: 10.1093/her/cyt115. View

18.

Headey D, Hoddinott J . Understanding the Rapid Reduction of Undernutrition in Nepal, 2001-2011. PLoS One. 2015; 10(12):e0145738. PMC: 4690594. DOI: 10.1371/journal.pone.0145738. View

19.

Jalal C, Frongillo E, Warren A . Food Insecurity Mediates the Effect of a Poverty-Alleviation Program on Psychosocial Health among the Ultra-Poor in Bangladesh. J Nutr. 2015; 145(8):1934-41. DOI: 10.3945/jn.115.210799. View

20.

Fairchild A, McDaniel H . Best (but oft-forgotten) practices: mediation analysis. Am J Clin Nutr. 2017; 105(6):1259-1271. PMC: 5445681. DOI: 10.3945/ajcn.117.152546. View