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Background Little is known about how the level of program participation affects child nutrition in rural interventions. Objectives This study examined the association between participation level in a nutrition-sensitive agriculture intervention and children's diet and anthropometric outcomes in rural Ghana. Methods Nutrition Links was a cluster randomized controlled trial (clinicaltrials.gov NCT01985243), which enrolled caregivers with children (aged less than 2 mo in 2014–2015 and less than 18 mo in 2016–2017). Of the 287 caregivers in 19 intervention communities who enrolled, 233 adopted the intervention and received layer poultry, garden inputs, and weekly child feeding education. The egg production and repayment of poultry were monitored, and feed was sold at the weekly meetings. After endline, the nutrition educators rated each woman who adopted the intervention on a scale [very poor (1) to excellent (5)] for: 1) meeting attendance, 2) egg productivity, 3) feed and poultry loan payment, 4) contributions during meetings, and 5) attentiveness towards group members. Participation level was classified as high, medium, and low by dividing the sum of these 5 items into tertiles; 54 women who did not adopt the intervention were classified as "no participation." Generalized mixed linear models tested the difference in changes in children's diet and anthropometric indices between the participation levels and the control category – 213 caregiver-child dyads in 20 communities who received standard-of-care health and agricultural services. Results Compared with the control category, only high participation was associated with egg consumption [adjusted OR (aOR) = 3.03; 95% CI: 1.15, 7.94]. Both medium and high participation levels were associated with length‐for‐age z ‐scores (LAZ)/height‐for‐age z ‐scores (HAZ) [adjusted β-coefficients (aβ) = 0.44; 95% CI: 0.16, 0.72 and 0.40; 95% CI: 0.12, 0.67, respectively]. Conclusion These results highlight the importance of promoting and monitoring the level of beneficiary participation to estimate the full potential of nutrition-sensitive agriculture interventions to improve nutritional outcomes. [ABSTRACT FROM AUTHOR]

Background Suboptimal infant and young child feeding (IYCF) practices contribute to child undernutrition. Sierra Leone Demographic and Health Survey data show that IYCF practices remain poor despite modest improvements. Recent studies have identified the role of grandmothers as critical to child nutrition; however, in Sierra Leone to date, the potential for grandmothers to influence IYCF practices has not been investigated. Objectives We examined how an innovative grandmother-inclusive approach (GMIA) can be used to address suboptimal IYCF practices. Methods Using a quasi-experimental design, we compared IYCF beliefs and practices between GMIA intervention communities (receiving monthly dialogue sessions on nutrition, quarterly community praise sessions, and intergenerational forums) and comparison communities (receiving standard nutrition education) in Bum chiefdom from 2013 and 2016. The quantitative endline survey targeted 101 pregnant women, 291 women with children aged <2 y, and 219 grandmothers. Statistical analyses utilized t tests and χ2 tests to examine differences between intervention and comparison communities at endline. Multivariate regression was used to determine the intervention's effect on IYCF outcomes of interest. Results Awareness of and participation in the GMIA was high among mothers and grandmothers in intervention communities. The percentage of infants and young children aged 0–23 mo (n  = 291) exclusively breastfed during the first week of life was significantly higher in the intervention group (90.2% compared with 79.4%, P  = 0.01). Among infants aged 6–23 mo (n  = 219), the percentage achieving minimum dietary diversity and minimum acceptable diet was significantly higher in the intervention group (77.2% compared with 51.8%, P  < 0.001; and 53.8% compared with 22.6%, P  < 0.001, respectively). Differences in percentages achieving minimum meal frequency (MMF) were only significant for infants aged 9–23 mo, with the intervention group achieving a higher MMF (54.6% compared with 36.9%, P  = 0.02). Conclusions Results suggest that a GMIA that recognizes grandmothers' roles and strengthens their knowledge can contribute to improved IYCF practices. [ABSTRACT FROM AUTHOR]

Background Global recommendations on optimal maternal and child nutrition (MCN) practices are clear; however, there is limited literature 1) exploring how roles of family members influence those practices and on 2) designing programs accordingly. Researchers using a family-systems approach in the Global South find that grandmothers often play a vital role in MCN, yet most nutrition programs narrowly target mothers, thereby potentially limiting effectiveness. Objectives This article reports on the results of qualitative research exploring the roles and influence of family members on MCN in southern Sierra Leone, the local MCN beliefs and practices, and how those findings informed the design of a culturally appropriate program. Methods Focus group discussions (FGDs) were conducted with mothers, fathers, and grandmothers in 9 communities in Bonthe District, Sierra Leone. We used participatory tools to explore family members' roles and local MCN beliefs and practices. Interviews were recorded by notetakers and coded and analyzed using a content analysis approach. Results A total of 88 mothers, 125 grandmothers, and 79 fathers participated in the FGDs. All groups indicated that 1) grandmothers are the culturally designated advisors and supervisors of women on MCN issues and 2) mothers are not autonomous decision makers and are greatly influenced by grandmothers. The research identified both beneficial MCN practices and gaps between optimal and existing MCN practices—particularly related to maternal diet during pregnancy and exclusive breastfeeding for 6 mo. Research findings were used to design a grandmother-inclusive program. Conclusions Our research showed that mothers are embedded in a family system of caring and supervision where grandmothers have primary influence on MCN practices, clearly supporting the need for grandmothers to have a central role in community MCN programs. It also points to the need for increased use of a family-systems approach in designing public health nutrition programs. [ABSTRACT FROM AUTHOR]