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Exclusive breastfeeding (EBF) provides significant health benefits to children. However, mothers may find it difficult to continue EBF for 6 months. The present analysis aimed to examine the influence of the Suchana intervention—a large‐scale programme implemented with the aim of improving the health and nutritional status of mothers and children from poor households in the Sylhet region of Bangladesh—on EBF and stunting among children under 6 months. Baseline and endline data were obtained from the Suchana evaluation. EBF was defined as an infant (<6 months) only receiving breast milk in the previous 24 h. Childhood stunting was defined as a length‐for‐age z‐score of less than −2 among children of the same age. Multiple logistic regression analysis was used to assess the associations of the Suchana intervention with EBF and stunting. EBF prevalence improved from 64% at baseline to 85% at the endline in the intervention area, with the intervention group having 2.25 times higher odds of EBF compared to the control group. Stunting prevalence reduced from 28% at baseline to 24% at the endline in the intervention group, but after controlling for covariates, the association between stunting and the intervention was not significant. However, the interaction analysis showed significantly lower stunting prevalence among EBF children in both intervention and control areas. The Suchana intervention had a positive impact on the EBF practice of rural children in a vulnerable region of Bangladesh, and EBF was identified as a significant factor associated with stunting. The findings suggest that the continuation of the EBF intervention has the potential to have an impact on reducing stunting in the region, highlighting the importance of promoting EBF to improve child health and development. Key messages: Suchana intervention in rural Bangladesh promoted exclusive breastfeeding (EBF) among mothers in the intervention group.EBF was found to be a significant factor associated with stunting in the study population.Better integration of determinants of stunting are needed to achieve a statistically significant reduction in stunting. [ABSTRACT FROM AUTHOR]

Women and children in Bangladesh face high levels of micronutrient deficiencies from inadequate diets. We evaluated the impact of a Homestead Food Production (HFP) intervention on poultry production, as a pathway outcome, and women's and children's egg consumption, as secondary outcomes, as part of the Food and Agricultural Approaches to Reducing Malnutrition cluster‐randomized trial in Sylhet division, Bangladesh. The 3‐year intervention (2015−2018) promoted home gardening, poultry rearing, and nutrition counseling. We randomly allocated 96 clusters to intervention (48 clusters; 1337 women) or control (48 clusters; 1368 women). Children < 3 years old born to participants were enrolled during the trial. We analyzed poultry production indicators, measured annually, and any egg consumption (24‐h recall), measured every 2−6 months for women and their children. We conducted intention‐to‐treat analyses using mixed‐effects logistic regression models with repeat measures, with minimal adjustment to increase precision. Poultry ownership increased by 16% points (pp) and egg production by 13 pp in the final intervention year. The intervention doubled women's odds of egg consumption in the final year (Odds Ratio [OR]: 2.31, 95% CI: 1.68−3.18), with positive effects sustained 1‐year post‐intervention (OR: 1.58, 95% CI: 1.16−2.15). Children's odds of egg consumption were increased in the final year (OR: 3.04, 95% CI: 1.87−4.95). Poultry ownership was associated with women's egg consumption, accounting for 12% of the total intervention effect, but not with children's egg consumption. Our findings demonstrate that an HFP program can have longer‐term positive effects on poultry production and women's and children's diets. Key messages: The Food and Agricultural Approaches to Reducing Malnutrition trial evaluated a 3‐year Homestead Food Production intervention that promoted small‐scale poultry rearing, home gardening, and nutrition counseling among women's groups in rural Sylhet division, Bangladesh.The intervention increased poultry ownership, egg production, and improved poultry management practices.The intervention increased women's and children's egg consumption, with the strongest effects in year 3 of the intervention and evidence of sustained impacts post‐intervention.The impact of the Homestead Food Production program on women's egg consumption was partly mediated by increased poultry ownership. [ABSTRACT FROM AUTHOR]

Context‐specific research is needed on the relationship between household animal production and nutrition outcomes to inform programmes intervening in small‐scale animal production. We examined associations between household animal/fishpond ownership and animal source food (ASF) consumption among 6‐ to 12‐month‐old infants enroled in the control arm of a cluster‐randomised controlled trial in rural Bangladesh. We measured ASF consumption using a 7‐day food frequency questionnaire at 6, 9 and 12 months and assessed household animal/fishpond ownership at 12 months. We developed negative binomial regression models with random intercepts for infant and cluster, controlling for infant age and sex, maternal age, socioeconomic status and season. Models were stratified by a dichotomised maternal decision‐making score. Compared with infants in households without each animal type, those with 4–10 and ≥11 poultry consumed eggs 1.3 (95% confidence interval [CI]: 1.1, 1.6) and 1.6 (95% CI: 1.3, 2.0) times more, respectively; 2–3 and ≥4 dairy‐producing animals consumed dairy 1.9 (95% CI: 1.3, 2.7) and 2.0 (95% CI: 1.3, 3.1) times more, respectively; and ≥12 meat‐producing animals consumed meat 1.4 (95% CI: 1.0, 1.8) times more. It was unclear whether there was an association between fishpond ownership and fish consumption. Our results did not suggest that maternal decision‐making power was a modifier in the relationship between animal/fishpond ownership and ASF consumption. In this South Asian context, strategies intervening in household animal production may increase infant consumption of eggs, dairy and meat, but not necessarily fish. Research is needed on the role of market access and other dimensions of women's empowerment. Key messages: Household ownership of poultry and dairy‐ and meat‐producing animals was associated with higher infant intakes of eggs, dairy and meat, respectively. There was not a clear association between household fishpond ownership and infant fish consumption.While we found no significant differences in these relationships by maternal decision‐making power, future research in this setting should consider the relative importance of other dimensions of women's empowerment or other contextual factors, such as market access.In Bangladesh and similar rural South Asian settings, programmes aiming to impact infant and child diet through agricultural interventions must assess the factors constraining both production and consumption. [ABSTRACT FROM AUTHOR]

Inadequate diet quality is a cause of undernutrition among children 6-23 months of age in Bangladesh, particularly in remote and isolated areas such as Bandarban District. Feeding animal source foods can help to combat stunting and wasting problems among children, but it may not be accessible or acceptable. A barrier analysis using the Designing for Behavior Change Framework was conducted in Bandarban district with participants from 4 ethnic groups, to explore potential barriers and key motivators by examining 12 behavioural determinants of consumption of animal-source food in complementary feeding for children 8-23 months. Data were collected from 45 mothers of children 8-23 months, who provided animal-source foods to their children (doers), and from 45 mothers who did not (non-doers), for a total of 90 interviews. Nine determinants were statistically significantly different between doers and non-doers as follows: self-efficacy, positive consequences, negative consequences, social norms, access, reminders, perceived risk, perceived severity and perceived action efficacy. Nearby access to purchase animal-source foods, rearing poultry or livestock at home and the support of household and community members are enablers to feeding animal-source food. In contrast, these same factors are barriers for non-doers. The lack of money to spend on animal-source foods is also a barrier. An integrated nutrition-sensitive and gender-transformative animal-based food production, and inclusive market programme could increase access to meat and eggs at the household level, increase opportunities to earn income and support gender-equitable household workloads and decision-making for optimal child feeding. [ABSTRACT FROM AUTHOR]

Agricultural development projects increasingly aim to improve health and nutrition outcomes, often by engaging women. Although evidence shows such projects can improve women's and children's health and nutrition and empower women, little is known about their impacts on women's health- and nutrition-related agency and the extent to which impacts emerge through women's empowerment, largely due to a lack of instruments that measure the dimensions of women's agency that are directly relevant to health and nutrition outcomes. We developed an optional, complementary module for the project-level women's empowerment in agriculture index (pro- WEAI) to measure health- and nutrition-related agency (pro-WEAI + HN). Our method for developing related indicators used data collected from six agricultural development programmes implemented across Bangladesh, Burkina Faso and Mali (pooled sample = 12,114) and applied psychometric analysis (exploratory and confirmatory factor analysis) and the Alkire-Foster methodology. Results revealed seven indicators covering women's agency in the areas of her own health and diet; her health and diet during pregnancy; her child's diet; breastfeeding and weaning; purchasing food and health products; and acquiring food and health products. Multigroup confirmatory factor analysis revealed measurement invariance across contexts and samples. Tests of association (Cramer's V) and redundancy suggest that the pro-WEAI + HN indicators measured aspects of agency that are distinct from the core pro-WEAI. The uptake of these indicators in studies of nutrition-sensitive agricultural development projects may strengthen the evidence on how such programming can enhance women's empowerment to improve health and nutrition outcomes for themselves and their children. [ABSTRACT FROM AUTHOR]

Bangladesh struggles with undernutrition in women and young children. Nutrition‐sensitive agriculture programmes can help address rural undernutrition. However, questions remain on the costs of multisectoral programmes. This study estimates the economic costs of the Targeting and Re‐aligning Agriculture to Improve Nutrition (TRAIN) programme, which integrated nutrition behaviour change and agricultural extension with a credit platform to support women's income generation. We used the Strengthening Economic Evaluation for Multisectoral Strategies for Nutrition (SEEMS‐Nutrition) approach. The approach aligns costs with a multisectoral nutrition typology, identifying inputs and costs along programme impact pathways. We measure and allocate costs for activities and inputs, combining expenditures and micro‐costing. Quantitative and qualitative data were collected retrospectively from implementers and beneficiaries. Expenditure data and economic costs were combined to calculate incremental economic costs. The intervention was designed around a randomised control trial. Incremental costs are presented by treatment arm. The total incremental cost was $795,040.34 for a 3.5‐year period. The annual incremental costs per household were US$65.37 (Arm 2), USD$114.15 (Arm 3) and $157.11 (Arm 4). Total costs were led by nutrition counselling (37%), agriculture extension (12%), supervision (12%), training (12%), monitoring and evaluation (9%) and community events (5%). Total input costs were led by personnel (68%), travel (12%) and supplies (7%). This study presents the total incremental costs of an agriculture‐nutrition intervention implemented through a microcredit platform. Costs per household compare favourably with similar interventions. Our results illustrate the value of a standardised costing approach for comparison with other multisectoral nutrition interventions. Key messages: Nutrition‐sensitive agriculture programmes can improve rural undernutrition but lack information on costs.We use a standardised approach to estimate the total incremental costs of an integrated nutrition intervention in Bangladesh to improve maternal and child undernutrition.Costs per household compare favourably with similar interventions.This study provides evidence on the costs of integration to support the design and implementation of multisectoral nutrition programmes.Our results illustrate the value of standardising costing to facilitate comparisons with other multisectoral nutrition interventions. [ABSTRACT FROM AUTHOR]

Community health workers (CHWs) increasingly provide interpersonal counselling to childbearing women and their families to improve adoption of recommended maternal and child nutrition behaviours. Little is known about CHWs' first‐hand experiences garnering family support for improving maternal nutrition and breastfeeding practices in low‐resource settings. Using focused ethnography, we drew insights from the strategies that CHWs used to persuade influential family members to support recommendations on maternal diet, rest and breastfeeding in a behaviour change communication trial in rural Bangladesh. We interviewed 35 CHWs providing at‐home interpersonal counselling to pregnant women and their families in seven 'Alive & Thrive' intervention sites. In‐depth probing focused on how CHWs addressed lack of family support. Thematic coding based on Fisher's narrative paradigm revealed strategic use of three rhetorical principles by CHWs: ethos (credibility), pathos (emotion) and logos (logic). CHWs reported selectively targeting pregnant women, husbands and mothers‐in‐law based on their influence on behavioural adoption. Key motivators to support recommended behaviours were improved foetal growth and child intelligence. Improved maternal health was the least motivating outcome, even among mothers. Logically coherent messaging resonated well with husbands, while empathetic counselling was additionally required for mothers. Mothers‐in‐law were most intransigent, but were persuaded via emotional appeals. Persuasion on maternal rest was most effort‐intensive, resulting in contextually appealing but scientifically inaccurate messaging. Our study demonstrates that CHWs can offer important insights on context‐relevant, feasible strategies to improve family support and uptake of nutrition recommendations. It also identifies the need for focused CHW training and monitoring to address scientifically flawed counselling narratives. Key messages: Analysis of narratives of nutrition‐promoting, rural Bangladeshi community health workers (CHWs) suggest that behavior change communication (BCC) strategies to persuade husbands require logical and credible information (logos and ethos) to establish their support, while childbearing women may additionally require emotional appeals (pathos) to adopt promoted behaviors. Mothers‐in‐law, who traditionally influence multiple nutrition behaviors, can be persuaded via strategic use of ethos and pathos.CHW communication strategies are useful in developing persuasive narratives that capture influential family members' value beliefs and outcome expectancies and promote behavior change. However, additional programmatic efforts are needed to discourage use of unscientific narratives by CHWs. [ABSTRACT FROM AUTHOR]

The World Health Organization (WHO) and United Nations Children's Fund (UNICEF) recommend exclusive breastfeeding (EBF) for the first 6 months of life. To estimate the proportion of infants that are exclusively breastfed, many agencies use the point prevalence of EBF among infants currently 0–5.9 months of age, as recommended by WHO and UNICEF. This measure tends to overestimate the percentage of infants that are exclusively breastfed for the entire recommended period. We compared five methods of measuring EBF, using data from three large‐scale cross‐sectional surveys. The five methods were: the WHO/UNICEF recommended method (EBF‐24H); an estimate of EBF for 6 months, using the 24‐h recall among infants 4–5.9 and 6–7.9 months (EBF‐24H‐Pul); a since birth recall (EBF‐SB); an estimate of EBF for 6 months, using the since‐birth recall among infants 4–5.9 and 6–7.9 months (EBF‐SB‐Pul); a retrospective measure of EBF collected from infants 6–11.9 months, based on the age of introduction of liquids and foods (EBF‐AI). EBF‐24H‐Pul and EBF‐SB‐Pul produced lower estimates of EBF than other measures, while also aligning better with the WHO recommendation, but may be difficult to estimate from multipurpose surveys due to sample size limitations. The EBF‐AI method produced estimates between these, aligns well with the WHO recommendation and can be easily collected in large‐scale household surveys. Additional validation of the EBF‐24‐Pul, EBF‐SB‐Pul, and EBF‐AI methods is recommended to understand how accurately they measure EBF for the recommended 6‐month period. Key points: Exclusive breastfeeding infants for the first 6 months of life is recommended by the World Health Organization and UNICEF for the benefits it provides to both the infant and the mother.The measure currently recommended for global monitoring of exclusive breastfeeding is the prevalence of exclusive breastfeeding among infants less than 6 months, based on a 24‐h recall.Though this measure is easy to collect in large‐scale household surveys, it is often misinterpreted as the percent of infants who are fed according to the recommendation, resulting in an overestimation.Other survey‐derived measures of exclusive breastfeeding are available, for example, such as calculating the midpoint prevalence among infants 4–5.9 and 6–7.9 months, a method developed by Pullum and a since birth recall among infants aged 6–11.9 months of age.These are similarly feasible to collect in household surveys and align better with the practice of exclusive breastfeeding for 6 months as recommended by the WHO. [ABSTRACT FROM AUTHOR]

Exclusive breastfeeding (EBF) for the first 6 months has established benefits, yet had slow improvements globally. Little is known about electronic job aid‐assisted counselling to support EBF. As a secondary outcome of a cluster randomized controlled trial in Bangladesh, we assessed the effect of electronic job aid‐supported nutrition counselling and practical demonstration on EBF. We randomized pregnant women to one of five study arms in the trial and followed mother–child dyads until 2 years of age. Community health workers (CHWs) provided breastfeeding counselling with or without prenatal and complementary nutrient supplements in all four intervention arms. The comparison arm continued with the usual practice where mothers could receive nutrition counselling at routine antenatal and postnatal care, and during careseeking for childhood illnesses. We assessed breastfeeding indicators at birth and monthly until the child was 6 months old, in both intervention and comparison arms. To evaluate the effect of nutrition counselling on breastfeeding, we combined all four intervention arms and compared them with the comparison arm. Intervention newborns had half the risk (relative risk [RR]: 0.54, 95% confidence interval [CI]: 0.39, 0.76) of receiving prelacteal feeds than those in the comparison arm. EBF declined steeply in the comparison arm after 3 months of age. EBF was 16% higher in the intervention than the comparison arm at 4 months (RR: 1.16, 95% CI: 1.08, 1.23) and 22% higher at 5 months of age (RR: 1.22, 95% CI: 1.12, 1.33). Maternal background and household characteristics did not modify the intervention effect, and we observed no difference in EBF among caesarean versus vaginal births. Breastfeeding counselling and practical demonstration using an electronic job aid by CHWs are promising interventions to improve EBF and are scalable into existing community‐based programmes. Key messages: Using an electronic job aid, repeated, one‐to‐one counselling and practical demonstration to mothers by locally recruited CHWs reduced prelacteal feeding and improved EBF practice by delaying the early introduction of complementary food.The positive effect of counselling on EBF remains similar with or without nutrient supplementation.Electronic job aid supported counselling to promote breastfeeding should be integrated into existing community‐based maternal and child health programmes. [ABSTRACT FROM AUTHOR]

The International Code of Marketing of Breast‐milk Substitutes (BMS) instituted to protect breastfeeding against unethical marketing, has been adopted by many countries, including Bangladesh. Despite national adoption, evidence suggests violations occur and inadequate BMS Code implementation is an issue. The study aimed to assess violations of the International BMS Code and the national 'Breast‐milk Substitutes, Infant Foods, Commercially Manufactured Complementary Foods and the Accessories Thereof (Regulation of Marketing) Act, 2013' of Bangladesh in commercial settings (retail outlets and media) in Bangladesh, for different types of milk, bottles, and teats using a standardized Network for Global Monitoring and Support for Implementation of the Code and Subsequent relevant World Health Assembly Resolutions (NetCode) protocol. This cross‐sectional quantitative study was conducted in Bangladesh from January to September 2018 in Dhaka, Chattogram, and Sylhet cities. Descriptive statistics were reported and χ2 tests were conducted to assess differences between categorical variables of interest. Data were analysed using SPSS version 20. In retail outlets, there were higher proportion of violations observed in Dhaka than in Sylhet and Chattogram (p < 0.001). Significantly greater proportion of violations in product labels occurred among products sold without local distributors compared to others (p < 0.05); violations were higher among "other milk" for children aged 0 to <36 months compared to formulas and growing‐up milk (p < 0.05). Among media channels, internet clips had significantly higher proportions of violations compared to television, radio and newspaper (p < 0.001). BMS Code violations were prevalent in product labels and promotion of products through retail outlets. The study findings highlight the need for specific multisectoral strategies for better enforcement of BMS Code and points to the need for periodic assessment of Code violations. Key messages: This is the first known study documenting violations in retail outlets, online stores, and media using the standard NetCode protocol in Bangladesh.BMS Code violations were high in retail stores and were more prevalent in the capital city compared to others.Violations were significantly higher in the internet compared to radio, television, and newspapers, highlighting the need for strengthening the monitoring of internet‐based promotions.It is essential to allocate resources to sensitize retail stores to the BMS Code to enhance the implementation of the law. [ABSTRACT FROM AUTHOR]

Adequate dietary diversity among infants is often suboptimal in developing countries. We assessed the impact of nutrition counselling using a digital job aid on dietary diversity of children aged 6–23 months using data from a cluster randomised controlled trial in Bangladesh. The trial had five arms, each with 25 clusters. The four intervention arms provided counselling using a digital job aid and different prenatal and post‐natal combinations of lipid‐based supplements and the comparison arm with usual practice. We enrolled 1500 pregnant women and followed them until the children reached their second birthday. We developed a tablet‐based system for intervention delivery, data collection and project supervision. We combined the four intervention arms (n = 855), in which community health workers (CHWs) provided age‐appropriate complementary feeding counselling, to compare against the comparison arm (n = 403). We calculated the outcome indicators from the children's 24‐h dietary recalls. Overall, the intervention increased the mean dietary diversity score by 0.09 (95% confidence interval [CI]: 0.2–0.16) and odds of minimum dietary diversity by 18% (95% CI: 0.99–1.40). However, there was a significant interaction on the effect of the intervention on dietary diversity by age. The mean dietary diversity score was 0.24 (95% CI: 0.11–0.37) higher in the intervention than in the comparison arm at 9 months and 0.14 (95% CI: 0.01–27) at 12 months of age. The intervention effect was non‐significant at an older age. Overall, consumption of flesh food was 1.32 times higher in the intervention arm (odds ratio [OR] 1.32, 95% CI: 1.11–1.57) in 6–23 months of age. The intervention significantly improved child dietary diversity score in households with mild and moderate food insecurity by 0.27 (95% CI: 0.06–0.49) and 0.16 (0.05–27), respectively, but not with food‐secure and severely food‐insecure households. Although the study did not evaluate the impact of digital job aid alone, the findings indicate the utility of nutrition counselling by CHWs using a digital job aid to improve child feeding practices in broader programmes. [ABSTRACT FROM AUTHOR]

Adequate maternal healthcare practices are crucial to both maternal and infant nutrition outcomes. The Sylhet region of Bangladesh is vulnerable and performs poorly, as maternal and child health indicators are falling behind compared to other areas. Suchana, a large‐scale intervention programme aims to improve the health and nutritional status of mothers and children in this region. The objective of the present analysis is to assess the changes in indicators related to maternal healthcare practices among Suchana beneficiaries. We obtained data from the Suchana baseline and endline evaluation survey. Descriptive statistics were employed to summarize data. The following maternal healthcare practices were considered: if a Suchana beneficiary mother received antenatal care (ANC) from skilled service providers, took day time resting during pregnancy, consumed additional diet during pregnancy, took at least 100 iron‐folic acid (IFA) tablets during pregnancy and took a vitamin A capsule after delivery. Logistic regression analysis was performed to assess the impact of the Suchana intervention on maternal healthcare practices. The prevalence of the outcome variables at endline in the intervention area were as follows: 40% of mothers received at least four ANC from skilled service providers, 50% practiced daytime resting during pregnancy, 51% consumed additional diet during pregnancy, 41% took at least 100 iron‐folic acid tablets during pregnancy, 39% received postnatal care and 30% took a vitamin A capsule after delivery. The Suchana intervention significantly, positively improved indicators related to maternal healthcare practices; these findings support future larger‐scale programmes to improve maternal healthcare practices among vulnerable people in rural Bangladesh. [ABSTRACT FROM AUTHOR]

Literature concerning negative impacts of domestic violence (DV) against women on their children's health is growing; however, little is known about the long‐term effect of maternal exposure to DV before and/or during pregnancy on their children's growth. Using data from the MINIMat cohort, we have evaluated the association between maternal lifetime experience of DV, measured in late pregnancy, with their children's linear growth at 15 years (n = 2240) in rural Bangladesh. A modified version of conflict tactic scale was used to record the maternal experience of physical, sexual, emotional DV and controlling behaviour. Children's height was measured by trained nurses during their clinical visits at 15‐year follow‐up. Compared to the women with no experience of DV, children of women with experience of any physical, sexual or emotional DV before and/or during pregnancy had the significantly lower height for age Z‐scores (HAZs) at the age of 15. No significant association between maternal experience of controlling behaviour and their children's linear growth was observed in terms of HAZ. Results from this study suggest that maternal experience of DV before and/or during pregnancy might be associated with impaired long‐term linear growth within their children. [ABSTRACT FROM AUTHOR]

In this study, we aimed to determine the prevalence and factors associated with overweight and obesity among nonpregnant and nonlactating (NPNL) women of reproductive age with iron deficiency anaemia (IDA) in urban Bangladesh. We obtained data from the baseline assessment of a randomized control trial conducted among 525 women of reproductive age (18–49 years) with IDA (Hb < 12 gdl−1 and serum ferritin <30 μg L−1). The study was carried out in Mirpur, Dhaka, Bangladesh, between December 2017 and January 2019. We collected information on women's socio‐demographic characteristics and anthropometry. Body mass index (BMI) was calculated using the following formula: weight in kilograms per height in square metres. BMI ≥ 25–29.9 kg m−2 was considered as overweight, whereas BMI ≥ 30 kg m−2 as obese. A multivariable logistic regression model was used to ascertain the risk factors of overweight and obesity. The prevalence of overweight and obesity was 29.9% (95% CI: 26.0–34.0) and 13.1% (95% CI: 10.4–16.3), respectively. The combined prevalence of overweight and obesity was 43.0% (95% CI: 38.7–47.4). The multivariable analysis showed married women (aOR: 4.4; CI: 1.8–11.1), women aged 30–49 years (aOR: 7.6; CI: 2.4–24.1), unemployed women (aOR 1.5; CI: 1.0–2.4) and women from the wealthier households (aOR 3.9; CI: 2.3–6.8) had the highest risk of being overweight and obese compared with their counterparts. Both age and household wealth statuses showed dose–response relationships. Combination of overweight and obesity with IDA poses a particular challenge for public health interventions. The policymakers should consider what new interventions and policy initiatives are needed to address this combination of overweight and obesity with IDA. [ABSTRACT FROM AUTHOR]

BRAC, an international development organization, implemented a home‐fortification programme from 2014 to 2018 in Bangladesh. This study aimed to understand the unintended consequences of programmatic changes that occurred during the implementation of the programme on the prevalence of good infant and young child feeding (IYCF) practices and other associated factors. We used pooled data from eight cross‐sectional surveys and data from a series of qualitative investigations carried out as part of a mixed‐methods evaluation approach. A total of 6,479 caregivers of children aged 6 to 23 months participated in the surveys. The prevalence of good IYCF practices increased from baseline (42.1%) to midline (45.3%), but it decreased at the endline survey (31.9%). Qualitative investigations identified several reasons for low IYCF practices at the programme level, such as the withdrawal of community health worker (CHW) incentives for promoting IYCF, providing incentives for the home‐fortification of micronutrient powder (MNP) and changing the focus from IYCF promotion to MNP promotion. A multivariable generalized estimating equation model for pooled data revealed that caregivers were 28% (adjusted risk ratio [ARR]: 0.72, 95% CI [0.67, 0.78]) less likely to maintain good IYCF practices during the period when CHWs were not incentivized to promote IYCF compared to the period when CHWs were incentivized to promote it. The prevalence of good IYCF practices decreased from both baseline and midline to the endline survey due to the unintended consequences of the programmatic changes. An integrated intervention strategy to promote the home‐fortification of MNP and IYCF could be helpful to avoid unintended negative consequences of programmatic changes. [ABSTRACT FROM AUTHOR]

Limited evidence exists on the complex relationship among interventions, early initiation of breastfeeding (EIBF), prelacteal feeding and exclusive breastfeeding (EBF). We examined whether early breastfeeding practices are associated with EBF and how much improving EIBF and non‐prelacteal feeding contributes to increased prevalence of EBF. Survey data were collected in 2010 and 2014 as part of impact evaluations of Alive & Thrive (A&T) interventions to improve infant and young child feeding (IYCF) practices in Bangladesh, Vietnam and Ethiopia. Multivariable logistic regression analyses were used to examine effects of interventions and early breastfeeding practices on EBF. Structural equation modelling quantified the direct and indirect effects of interventions (via improving EIBF and non‐prelacteal feeding) on EBF. Although breastfeeding is nearly universal in all three countries (≥98%), delayed initiation of breastfeeding is prevalent (>60%) and prelacteal feeding is common. EIBF alone was not associated with EBF, whereas non‐prelacteal feeding was associated with 1.6–3.5 higher odds of EBF. Intervention exposure affected breastfeeding practices in all three countries; these impacts were amplified among those who practiced EIBF or non‐prelacteal feeding [odds ratio (OR) = 11 and 27.5 in Bangladesh and 6.5 and 11.5 in Vietnam, respectively]. The paths through EIBF and non‐prelacteal feeding explained 13%–18% of the effect of the interventions on EBF. Early breastfeeding practices influence EBF, but interventions aimed only at the initiation and early days of breastfeeding will be inadequate to promote EBF. Social and behaviour change interventions should simultaneously target EIBF, non‐prelacteal feeding and EBF to support optimal breastfeeding practices. [ABSTRACT FROM AUTHOR]

Childhood obesity has been associated with consumption of energy‐dense foods such as caloric beverages and fast foods. Many low‐ and middle‐income countries like Bangladesh are now experiencing a rising problem of noncommunicable diseases along with the long‐standing problem of stunting and undernutrition. WASH Benefits Bangladesh was a large community‐based cluster randomized controlled trial conducted in rural Bangladesh. Study clusters were randomized into seven arms: single nutrition (N); water (W); sanitation (S); hygiene (H); combined water, sanitation, and hygiene (WSH); WSH and nutrition (N + WSH); and a double sized control (C). Nutrition intervention messages included four promotional components: maternal nutrition, breastfeeding, complementary feeding, and lipid‐based nutrient supplements. The World Health Organization infant food frequency questionnaire (24‐hr recall and 7‐day recall) was administered at Year 1 and Year 2 of intervention. The likelihood of any snack food consumption was significantly lower (odds ratio 0.37: 95% confidence interval [0.28, 0.49]) in the nutrition intervention arms compared to the control arm in Year 2 follow‐up. In addition, in the water intervention arm, fewer children (about 50% less) consumed soft drinks, but not the other sugar‐sweetened beverages, compared with control in Year 2. There were no other differences between groups. Simple messages about balanced diet and feeding family foods were effective in lowering commercially produced snack food consumption of the young children in low‐income rural communities of Bangladesh. Provision of safe water apparently encouraged mothers to reduce offering unhealthy beverages to the young children. [ABSTRACT FROM AUTHOR]

Care is important for children's growth and development, but lack or inadequacy of resources for care can constrain appropriate caregiving. The objectives of this study were to examine whether maternal resources for care are associated with care behaviours specifically infant and young child feeding, hygiene, health‐seeking, and family care behaviours. The study also examined if some resources for care are more important than others. This study used baseline Alive & Thrive household surveys from Bangladesh, Vietnam, and Ethiopia. Measures of resources for care were maternal education, knowledge, height, nourishment, mental well‐being, decision‐making autonomy, employment, support in chores, and perceived instrumental support. Multiple regression analyses were conducted to examine the associations of resources for care with child‐feeding practices (exclusive breastfeeding, minimum meal frequency, dietary and diversity), hygiene practices (improved drinking water source, improved sanitation, and cleanliness), health‐seeking (full immunization), and family care (psychosocial stimulation and availability of adequate caregiver). The models were adjusted for covariates at child, parents, and household levels and accounted for geographic clustering. All measures of resources for care had positive associations with care behaviours; in a few instances, however, the associations between the resources for care and care behaviours were in the negative direction. Improving education, knowledge, nutritional status, mental well‐being, autonomy, and social support among mothers would facilitate provision of optimal care for children. [ABSTRACT FROM AUTHOR]

Undernutrition may affect fecundability, but few studies have quantified this relationship. In rural Bangladesh, where newlywed couples face strong pressures to become pregnant, we assessed fecundability, estimated by time to pregnancy (TTP), and its association with preconceptional thinness among nulligravid, newlywed female adolescents. During 2001–2002, 5,516 newlywed women aged 12–19 years participated in a home‐based, 5‐weekly surveillance system for 5–6 years to enrol pregnant women into an antenatal vitamin A or β‐carotene supplementation trial. Thinness was defined as a left mid‐upper arm circumference (MUAC) ≤21.5 versus >21.5 cm. At each visit, staff obtained a monthly history of menstruation. Report of amenorrhea prompted a human chorionic gonadotropin urine test to confirm pregnancy. We derived hazard ratios (with 95% confidence intervals [CI]) for pregnancy and Kaplan–Meier curves for TTP. Ages of women at marriage and pregnancy detection (mean ± standard deviation) were 15.3 ± 1.9 and 17.0 ± 1.9 years, respectively. A total of 82.7% of thinner and 87.3% of better nourished women became pregnant. The unadjusted and multivariable relative hazard of ever becoming pregnant was 0.84 (95% CI [0.78, 0.89]) and 0.86 (95% CI [0.81, 0.92]), respectively, and TTP was 12 weeks longer (median [95% CI]: 63 [58–68] vs. 51 [49–54]) in women whose MUAC was ≤21.5 versus >21.5 cm. In rural Bangladesh, thin adolescent newlywed girls have a lower probability of becoming pregnant and experience a longer time to pregnancy. [ABSTRACT FROM AUTHOR]

Prenatal nutritional supplements may improve birth outcomes. This study aims to examine the effect of prenatal lipid‐based nutrient supplements (LNS), compared with iron and folic acid (IFA), on general newborn physical condition and feeding behaviours. We conducted a cluster‐randomized effectiveness trial that enrolled 4,011 pregnant women at ≤20 gestational weeks. LNS and IFA were provided to women in 48 and 16 clusters, respectively, for daily consumption until delivery. We collected data on household socio‐economic, food insecurity, and maternal characteristics during early pregnancy and on newborn condition and feeding within 72 hr of delivery. We analysed intervention effects on these secondary outcomes using mixed models with analysis of covariance for continuous outcomes and logistic regression for dichotomous outcomes. Among 3,664 live births, intervention groups did not differ in newborn response, mother's rating of the general condition of her newborn, early initiation of breastfeeding (EIBF), suckling ability, or frequency and exclusivity of breastfeeding in the first 24 hr. If the mother perceived her infant to be healthy, EIBF was more likely (OR [95% CI]: 2.08 [1.46, 2.97]) and frequency of breastfeeding in the first 24 hr was greater (mean difference [95% CI]: 3.0 [1.91, 4.01]), but there was no difference in exclusive breastfeeding in the first 24 hr. Newborn condition and early breastfeeding practices were not affected by giving mothers prenatal LNS versus IFA. However, early breastfeeding practices were related to maternal perception of her newborn's condition. Thus, interventions to improve breastfeeding practices for newborns with poorer perceived health status may be useful. [ABSTRACT FROM AUTHOR]

The relationship between women's empowerment and women's nutrition is understudied. We aimed to elucidate this relationship by quantifying possible pathways between empowerment and dietary diversity among women in rural Bangladesh. In 2015, we conducted a cross-sectional survey of 2,599 married women ages 15-40 (median: 25) living in 96 settlements of Habiganj District, Bangladesh, as a baseline for the Food and Agricultural Approaches to Reducing Malnutrition trial. We collected data on women's empowerment (highest completed grade of schooling and agency), dietary diversity, and demographic factors, including household wealth. We used exploratory factor analysis and confirmatory factor analysis on random split-half samples, followed by structural equation modelling, to test pathways from schooling, through domains of women's agency, to dietary diversity. Factor analysis revealed 3 latent domains of women's agency: social solidarity, decision-making, and voice with husband. In the adjusted mediation model, having any postprimary schooling was positively associated with voice with husband (β41 = .051, p = .010), which was positively associated with dietary diversity (β54 = .39, p = .002). Schooling also had a direct positive association with women's dietary diversity (β51 = .22, p < .001). Neither women's social solidarity nor decision-making mediated the relationship between schooling and dietary diversity. The link between schooling and dietary diversity was direct and indirect, through women's voice with husband but not through women's social solidarity or decision-making. In this population, women with postprimary schooling seem to be better able to negotiate improved diets for themselves. [ABSTRACT FROM AUTHOR]

Appetite in children is an important determinant of nutritional intake and growth. The information used by caregivers to understand children's appetite can help inform infant and young child feeding promotion and appetite assessment. We conducted a qualitative study to (a) explore maternal perceptions and responses to children's appetite and (b) to identify how these factors differ by type of caregiver, level of maternal experience, and urban versus rural context. We used purposive sampling to recruit mothers and alternate caregivers into 14 total focus group discussions (six to eight participants in each group; N = 95) in both urban and rural settings in Bangladesh. To understand children's appetite, caregivers monitor children's dietary patterns, emotional signs, and physical and verbal cues. Healthy appetite was observed by willingness to eat diverse foods, finish offered portions, and by acceptance of foods without excessive prompting. Child illness was cited for a cause of low appetite, which was manifested through fussiness, and avoiding commonly consumed foods. Mothers described a limited set of feeding practices (offering diverse foods, playing, and cheering children with videos) to encourage consumption when children lacked appetite. Mothers' stress related to work was noted as a barrier to identifying appetite cues. Urban mothers described a lower access to instrumental social support for child feeding but informational support than mothers in the rural setting. Understanding caregivers' perceptions of children's appetite may inform strategies to improve responsive feeding and tool development to assess changes in appetite as early indicators of change in health or nutrition status among high-risk children. [ABSTRACT FROM AUTHOR]

Behaviour change communication (BCC) can improve infant and young child nutrition (IYCN) knowledge, practices, and health outcomes. However, few studies have examined whether the improved knowledge persists after BCC activities end. This paper assesses the effect of nutrition sensitive social protection interventions on IYCN knowledge in rural Bangladesh, both during and after intervention activities. We use data from two, 2-year, cluster randomised control trials that included nutrition BCC in some treatment arms. These data were collected at intervention baseline, midline, and endline, and 6-10 months after the intervention ended. We analyse data on IYCN knowledge from the same 2,341 women over these 4 survey rounds. We construct a number correct score on 18 IYCN knowledge questions and assess whether the impact of the BCC changes over time for the different treatment groups. Effects are estimated using ordinary least squares accounting for the clustered design of the study. There are 3 main findings: First, the BCC improves IYCN knowledge substantially in the 1st year of the intervention; participants correctly answer 3.0-3.2 more questions (36% more) compared to the non-BCC groups. Second, the increase in knowledge between the 1st and 2nd year was smaller, an additional 0.7-0.9 correct answers. Third, knowledge persists; there are no significant decreases in IYCN knowledge 6-10 months after nutrition BCC activities ended. [ABSTRACT FROM AUTHOR]

The lipid composition of breast milk may have a significant impact on early infant growth and cognitive development. Comprehensive breast milk data is lacking from low-income populations in the Indian subcontinent impeding assessment of deficiencies and limiting development of maternal nutritional interventions. A single breast milk specimen was collected within 6 weeks postpartum from two low-income maternal cohorts of exclusively breastfed infants, from Dhaka, Bangladesh ( n = 683) and Kolkata, India ( n = 372) and assayed for percentage composition of 26 fatty acids. Mature milk (>15 days) in Dhaka ( n = 99) compared to Kolkata ( n = 372) was higher in total saturated fatty acid (SFA; mean 48% vs. 44%) and disproportionately lower in ω3-polyunsaturated fatty acid (PUFA), hence the ω6- and ω3-PUFA ratio in Dhaka were almost double the value in Kolkata. In both sites, after adjusting for days of lactation, increased maternal education was associated with decreased SFA and PUFA, and increasing birth order or total pregnancies was associated with decreasing ω6-PUFA or ω3-PUFA by a factor of 0.95 for each birth and pregnancy. In Dhaka, household prosperity was associated with decreased SFA and PUFA and increased ω6- and ω3-PUFA. Maternal height was associated with increased SFA and PUFA in Kolkata (1% increase per 1 cm), but body mass index showed no independent association with either ratio in either cohort. In summary, the socioeconomic factors of maternal education and household prosperity were associated with breast milk composition, although prosperity may only be important in higher cost of living communities. Associated maternal biological factors were height and infant birth order, but not adiposity. Further study is needed to elucidate the underlying mechanisms of these effects. [ABSTRACT FROM AUTHOR]

In many low‐income countries, girls marry early and have children very soon after marriage. Although conveying infant and young child nutrition (IYCN) knowledge to adolescent girls in time is important to ensure the well‐being of their children, little is known about the best ways to convey these messages. This study examines the extent of, and sources from which adolescent girls derive IYCN knowledge in order to inform the design of programmes that convey such information. Data on adolescent girls aged 12–18 was collected in 2013 in 140 clusters of villages in rural areas (n = 436), and 70 clusters of slums in urban areas (n = 345) in Bangladesh. Data were analysed using multivariable Poisson regression models. In both the urban and rural samples, girls' schooling is positively and significantly associated with IYCN knowledge (P < 0.01 and P < 0.10, respectively). IYCN knowledge of adolescent girls' mothers is also associated with adolescents' IYCN knowledge in both urban and rural samples, but the magnitude of association in the urban sample is only half that of the rural sample (P < 0.01 and P < 0.10, respectively). In Bangladesh, efforts to improve knowledge regarding IYCN are typically focused on mothers of young children. Only some of this knowledge is passed onto adolescent girls living in the same household. As other messaging efforts directed towards mothers have only small, or no association with adolescent girls' knowledge of IYCN, improving adolescent girls' IYCN knowledge may require information and messaging specifically directed towards them. © 2016 John Wiley & Sons Ltd [ABSTRACT FROM AUTHOR]

Within a Medecins Sans Frontieres's nutrition programme in Kamrangirchar slum, Dhaka, Bangladesh this study was conducted to assess the acceptability of a peanut‐based ready‐to‐use therapeutic food (RUTF) – Plumpy'nut® (PPN) among malnourished pregnant and lactating women (PLW). This was a cross‐sectional survey using semi‐structure questionnaire that included all PLW admitted in the nutrition programme, who were either malnourished or at risk of malnutrition and who had received PPN for at least 4 weeks. A total of 248 women were interviewed of whom 99.6% were at risk of malnutrition. Overall, 212 (85%) perceived a therapeutic benefit. Despite this finding, 193 (78%) women found PPN unacceptable, of whom 12 (5%) completely rejected it after 4 weeks of intake. Reasons for unacceptability included undesirable taste (60%) and unwelcome smell (43%) – more than half of the latter was due to the peanut‐based smell. Overall, 39% attributed side effects to PPN intake including nausea, vomiting, diarrhoea, abdominal distension and pain. Nearly 80% of women felt a need to improve PPN – 82% desiring a change in taste and 48% desiring a change in smell. Overall, only 146 (59%) understood the illustrated instructions on the package. Despite a perceived beneficial therapeutic effect, only two in 10 women found PPN acceptable for nutritional rehabilitation. We urge nutritional agencies and manufacturers to intensify their efforts towards developing more RUTF alternatives that have improved palatability and smell for adults and that have adequate therapeutic contents for treating malnourished PLW in Bangladesh. [ABSTRACT FROM AUTHOR]

Birth size is an important gauge of fetal and neonatal health. Birth size measurements were collected within 72 h of life for 16 290 live born, singleton infants in rural Bangladesh from 2004 to 2007. Gestational age was calculated based on the date of last menstrual period. Newborns were classified as small‐for‐gestational age (SGA) based on a birthweight below the 10th percentile for gestational age, using three sets of US reference data. Birth size distributions were explored based on raw values as well as after z‐score standardisation in reference to World Health Organization (WHO) 2006 growth standards. Mean (SD) birthweight (g), length (cm) and head circumference (cm) measurements, completed within [median (25th, 75th percentile)] 15 (8, 23) h of life, were 2433 (425), 46.4 (2.4) and 32.4 (1.6), respectively. Twenty‐two per cent were born preterm. Over one‐half (55.3%) of infants were born low birthweight; 46.6%, 37.0% and 33.6% had a weight, length and head circumference below −2 z‐scores of the WHO growth standard at birth; and 70.9%, 72.2% and 59.8% were SGA for weight based on Alexander et al., Oken et al. and Olsen et al. references, respectively. Infants in this typical rural Bangladesh setting were commonly born small, reflecting a high burden of fetal growth restriction and preterm birth. Our findings, produced by active birth surveillance, suggest that low birthweight is far more common than suggested by cross‐sectional survey estimates. Interventions that improve fetal growth during pregnancy may have the largest impact on reducing SGA rates. [ABSTRACT FROM AUTHOR]

Growth patterns in early life are associated with later health. The effect of nutrition during in utero development on later body composition is unclear. We evaluated whether prenatal early invitation to food and/or multiple micronutrient supplementation ( MMS) in pregnancy has an effect on offspring body composition at 54 months of age. In Maternal and Infant Nutrition Interventions in Matlab trial ( ISRCTN16581394) in Bangladesh, 4436 pregnant women were randomised into six equally sized groups: double-masked supplementation with capsules of either 30 mg Fe and 400 μg folic acid, or 60 mg Fe and 400 μg folic acid, or MMS (15 micronutrients), was combined with a randomised early invitation (around 9 weeks) or a usual invitation (around 20 weeks) to start food supplementation (608 kcal 6 days per week). At 54 months, the body composition of the offspring was assessed by leg-to-leg bioelectrical impedance analysis. Of the 3267 live singletons with birth anthropometry, 2290 children were measured at 54 months, representing 70% of the live births. There was no interaction between the food and micronutrient supplementation on body composition outcomes. There were no significant differences in a range of anthropometric and body composition measurements, including weight, height, mid-upper arm circumference, head circumference, skinfold thickness, and fat mass and fat-free mass between the different prenatal food and micronutrient groups using an intention-to-treat analysis. This analysis shows that early invitation to food supplementation and MMS provided to rural Bangladeshi women during pregnancy did not affect offspring body composition at 54 months of age. [ABSTRACT FROM AUTHOR]

Stunting in children is a global public health concern. We investigated how global DNA methylation relates to food intakes, dietary diversity, and development of stunting among 324 children aged 24–36 months in a slum community in Dhaka, Bangladesh. Stunted children (height‐for‐age z score ˂−2; n = 162) and their age‐ and sex‐matched nonstunted counterparts (height‐for‐age z score ˃−1; n = 162) were selected by active community surveillance. We studied global DNA methylation, measured as 5‐mC% content in whole blood. Dietary intake, anthropometric measurement, and sociodemographic information were obtained. In the multiple linear regression model, increased global DNA methylation level in children was significantly associated with consumption of lower amount of energy, coef:.034 (95% CI [.014,.053]); P = .001, protein, coef:.038 (95% CI [.019,.057]); P = .000, carbohydrate, coef:.027 (95% CI [.008,.047]); P = .006, zinc, coef:.020 (95% CI [.001,.039]); P = .043, total dietary intakes, coef:.020 (95% CI [.001,.039]); P = .043, and intake from plant sources, coef:.028 (95% CI [.009,.047]); P = .005, after adjusting for other covariates. Moreover, higher fruits and vegetables consumption was significantly associated with lower 5‐mC% level, coef: −.022 (95% CI [−.041, −.002]); P = .028. Our findings suggest a significant association between low dietary intakes and increased global DNA methylation. We also found increased global DNA methylation in stunted children. To establish the relationship among the macronutrient intakes, global DNA methylation, and stunting, future prospective studies are warranted in resource‐poor settings. [ABSTRACT FROM AUTHOR]

The Essential Nutrition Actions (ENA) framework is an evidence‐based set of cost‐effective, integrated tools for training health and community workers to promote optimal nutrition practices for the first 1,000 days. This ENA pilot project (ENAPP) was implemented with United States Agency for International Development (USAID) funding from August 2008 to September 2009 in six unions of the working area of an existing USAID‐funded, Title II programme in southern Bangladesh. ENAPP, which targeted governmental and non‐governmental service providers, was intended to strengthen the behaviour change component of the nutrition strategy of this project. Following a qualitative review of ENAPP's activities, this evaluation uses administrative (growth monitoring) data and propensity score matching of pre‐intervention characteristics to create multiple counterfactuals for difference‐in‐difference estimations of the impact of ENAPP on child nutritional status. Records indicated that government and community healthcare workers received intensive training, and these staff reported that they could effectively integrate ENA messages into their existing responsibilities. Both longitudinal and cross‐sectional analyses indicate that ENAPP was successful in increasing children's weight‐for‐age z‐scores, and the difference in z‐scores between the treatment and the comparison group increased with time. The materials and methods used in this pilot project should be scaled up, based on the success of these tools and the project's ability to link with and influence the local health system. [ABSTRACT FROM AUTHOR]

Globally, undernutrition affects nearly half of all children aged less than 5 years. It is more prominent in low- and middle-income countries. This study aimed to identify the age-specific risk factors for different categories of undernutrition among Bangladeshi children aged less than 2 years. Data of 10,291 children aged less than 2 years were collected between October 2011 to November 2013 through the Food Security Nutritional Surveillance Project in Bangladesh. Simple logistic regression established bivariate relationships between the categories of undernutrition and the relevant risk factors. Multiple logistic regression constructed the age-specific regression models depicting the independent association and effect size of the risk factors contributing to the various categories of undernutrition among study population. Stunting was prevalent among 30.9% of the study children, whereas 9.7% were wasted and 24.9% were underweight. Being a male child, increase in age, maternal body mass index and education, and household food insecurity were the strongest predictors for all categories of undernutrition in terms of effect size. Our study shows that the different categories of childhood undernutrition have different age-specific risk factors. Maternal body mass index and household food insecurity were the common age-specific risk factors for all categories of undernutrition. We expect our findings to enhance the existing evidence base for the risk factors of undernutrition among children aged less than 2 years. [ABSTRACT FROM AUTHOR]