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Objectives: The United Nations recommends that women consume ≥5 food groups, also known as the minimum dietary diversity score for women (MDD-W), for nutritional health. This is increasingly unattainable for populations in climate hot zones coping with food insecurity by prioritizing calories over dietary breadth. Breastfeeding mothers may be particularly vulnerable to adverse health impacts of low dietary diversity due to elevated nutritional requirements for lactation. We investigated how the protective effects of MDD-W for folate adequacy varies by MDD-W score and mother-infant life history characteristics., Methods: We conducted a secondary analysis of cross-sectional data from breastfeeding mothers (n = 228) in northern Kenya, surveyed during the 2006 Horn-of-Africa drought. Logistic regression models for adequate dietary folate (and vitamins B12 and B6) and normal homocysteine (folate-replete status) evaluated the effect of MDD-W alone and in interaction with infant/maternal characteristics., Results: MDD-W (as ordinal or dichotomous variable) was positively associated with adequate folate (and vitamin B12). Having male infant was inversely associated with adequate dietary folate. MDD-W was generally unassociated with homocysteine. However, there was an interaction between MDD-W and sex of the infant. Namely, MDD-W ≥ 3 predicted increased probability of normal homocysteine among mothers with female infants but not male infants., Conclusions: Diets consisting of three or more food groups may protect adequate folate intake for many breastfeeding mothers. More research is needed to establish what level of dietary diversity would protect against hyperhomocysteinemia during breastfeeding and what factors promote or hinder the benefit of diversified diets on maternal folate nutrition., (© 2024 The Author(s). American Journal of Human Biology published by Wiley Periodicals LLC.)

This study explores common factors associated with not meeting minimum dietary diversity (MDD) among 27,072 children aged 6–23 months in Eastern and Southern Africa using data from nine Demographic and Health Surveys from 2013 to 2016. MDD was defined as consumption of more than or equals to five of eight food groups including breast milk in the past 24 h. Equity gaps were calculated as the difference in MDD prevalence between the top and bottom wealth quintiles. Logistic regression was conducted to identify common factors for not meeting MDD at the household, maternal and child levels across two or more countries to inform regional policies to improve children's diets. Kenya had the highest MDD wealth equity gap (40.4 pts), and South Africa had the smallest (14.4 pts). Equity gaps for flesh foods or eggs (up to 39.8 pp) were larger than for grain or legumes (up to 20 pp). Common risk factors for not reaching MDD included younger child age (6–11 months) (n = 9 countries), no formal maternal occupation (n = 6), not receiving vitamin‐A supplementation (n = 3), younger maternal age (n = 3), lower maternal education (n = 3), no media (n = 3) or newspaper (n = 3) exposure, lower household wealth quintile (n = 3), use of nonefficient cooking fuel (n = 2), longer time to get to the water source (n = 2), not listening to the radio (n = 2) and higher birth order (n = 2). Priorities for improving MDD in the region include introducing diverse foods at a young age from 6 months with early nutrition counselling, promoting higher maternal education, increasing food purchasing power and ensuring the support of younger mothers. Key messages: Diets of children in Eastern and Southern Africa (ESA) lack diversity.A number of common risk factors predict dietary diversity across countries.Risk factors for low dietary diversity include wealth, education and media access.Wide equity gaps were apparent for most food groups in ESA.Interventions addressing affordability and access to diverse diets are needed. [ABSTRACT FROM AUTHOR]

Objectives: Diarrhoea is a leading cause of infant mortality with the main transmission pathways being unsafe water and contaminated food, surfaces and hands. The 'Safe Start' trial evaluated a food hygiene intervention implemented in a peri-urban settlement of Kisumu, Kenya, with the aim of reducing diarrhoeagenic enteric infections among infants. Four food hygiene behaviours were targeted: handwashing with soap before preparation and feeding, boiling infant food before feeding, storing infant food in sealed containers, and exclusive use of designated utensils during feeding. Methods: A process evaluation of the intervention was guided by a theory of change describing the hypothesised implementation and receipt of the intervention, mechanisms of change, and the context. These were assessed by qualitative and quantitative data that included debriefing sessions with the delivery teams and Community Health Volunteers (CHVs), and structured observations during food preparation. Results: The intervention achieved high coverage and fidelity with over 90% of 814 eligible caregivers participating in the intervention. Caregivers in the intervention arm demonstrated an understanding of the intervention messages, and had 1.38 (95% CI: 1.02–1.87) times the odds of washing hands before food preparation and 3.5 (95% CI: 1.91–6.56) times the odds of using a feeding utensil compared to caregivers in the control group. Contextual factors, especially the movement of caregivers within and outside the study area and time constraints faced by caregivers influenced uptake of some intervention behaviours. Conclusion: Future interventions should seek to explicitly target contextual factors such as secondary caregivers and promote food hygiene interventions as independent of each other. Significance: What is already known on this subject. Diarrhoea is known to be a significant cause of infant morbidity and mortality, mainly through unsafe water and food, and mainly from rural areas. What this study adds. This study describes the implementation of a novel food hygiene intervention to reduce diarrhoea causing enteric infections among children in low income peri urban settlements. The manuscript details the delivery of the intervention, describes the context, and explores associations influencing adoption of the intervention. Findings of the evaluation are meant to support the results of the trial. [ABSTRACT FROM AUTHOR]

We aimed to describe the co‐occurrence of known risk factors for undernutrition and the prevalence of modifiable risks in wasted, stunted and healthy children. Quota sampling was used to recruit healthy [weight for age Z scores (WAZ) > −2 SD] and undernourished [weight for length (WLZ) or WAZ scores ≤ −2 SD] children aged 6–24 months from seven clinics in low‐income areas of Nairobi. Structured interviews were used to identify exposure to socioeconomic, water and hygiene, infant feeding, dietary and behavioural risks (low interest in food, high food refusal and force feeding). We recruited 92 wasted WLZ ≤ −2 SD, 133 stunted (length for age Z scores LAZ ≤ −2 SD) and 172 healthy (LAZ and WLZ > 2SD) children. Nearly all children were exposed to hygiene risks (90%) and low dietary diversity (95%) regardless of nutritional status. Stunted children were more likely to be exposed to socio‐economic risks (54% healthy, 64% wasted and 72% stunted; P = 0.001). Compared with healthy children, wasted and stunted children were more likely to be exposed to infant feeding (25% healthy, 40% wasted and 41% stunted; P = 0.02) and behaviour risks (24% healthy, 49% wasted, and 44% stunted; P = 0.004). Overall, wasted and stunted children were twice as likely to be exposed to more than three risks (23% healthy, 48% wasted, and 50% stunted; P = <0.001). They were also more likely to be exposed to more than three modifiable risks (dietary, handwashing and behaviour risks). Wasting and stunting are associated with exposure to multiple risk factors, many of which are potentially modifiable using targeted advice. [ABSTRACT FROM AUTHOR]

Grandmothers and fathers are key influencers of maternal and child nutrition and are increasingly included in interventions. Yet, there is limited research exploring their experiences participating in interventions. This study reports on findings from a qualitative process evaluation of a quasi‐experimental study that we conducted with grandmother and father peer dialogue groups to support maternal, infant and young child feeding practices in western Kenya. The aim was to explore grandmother and father experiences participating in interventions and how participation influences care and feeding practices. Grandmother and father peer educators received training to facilitate discussions about maternal and child nutrition, HIV and infant feeding, family communication, and family members' roles. Father peer educators also received training on gender inequities and power dynamics. In the original quasi‐experimental study, the intervention was associated with increased social support and improvements in some complementary feeding practices. The process evaluation explored participants' experiences and how participation influenced infant care and feeding practices. We used Atlas.ti to thematically analyse data from 18 focus group discussions. The focus group discussions revealed that grandmothers and fathers valued their groups, the topics discussed and what they learned. Grandmothers reported improved infant feeding and hygiene practices, and fathers reported increased involvement in child care and feeding and helping with household tasks. Both described improved relationships with daughters‐in‐law or wives. This study highlights the importance of engaging influential family members to support child nutrition and identifies factors to build cohesion among group members, by building on grandmothers' roles as advisors and expanding fathers' roles in nutrition through gender transformative activities. [ABSTRACT FROM AUTHOR]

Optimal complementary feeding practices including consumption of multiple micronutrient powders (MNP) are recommended to improve micronutrient intake by infants and young children (IYC) 6–23 months. Formative research was used to design the behaviour change strategy to improve IYC micronutrient intake for the multicountry ENRICH project in rural impoverished areas of Tanzania, Kenya, Bangladesh and Pakistan. Employing a qualitative approach with multiple methods and guided by a social ecological framework, the study was conducted in several phases: data collection in the community, household and health facilities, initial analysis and household trials (HHT). Results found limited use of animal source foods (ASF) for feeding IYC and MNP largely unavailable. Although cost constrained access to ASF, potential more affordable context‐specific ASF options were identified in each setting. Caregivers associated ASF with many positive attributes for IYC, but barriers to feeding them included lack of caregiver time and knowledge of specific preparation techniques, and limited advice from health workers. Feeding practices were identified that used time‐efficient, specific preparations for eggs and other ASF, and demonstrated good initial acceptability and feasibility during HHT. Testing MNP in HHT found good initial feasibility and acceptability and provided an understanding of the facilitators and constraints for preparing, feeding and promoting MNP. In conclusion, formative research led to the design of context‐specific ASF and MNP complementary feeding promotion strategies to improve IYC consumption of micronutrients by identifying the practices, benefits, motivations and alternative actions to overcome the barriers in each setting. [ABSTRACT FROM AUTHOR]

Background: Child mortality rates during hospitalisation for acute illness and after discharge are unacceptably high in many under-resourced settings. Childhood vulnerability to recurrent illness, and death, is linked to their families' situations and ability to make choices and act (their agency). We examined vulnerability and agency across treatment-seeking journeys for acutely ill children and considered the implications for policy and practice. Method: A qualitative sub-study was embedded within the prospective CHAIN Network cohort study, which is investigating mechanisms of inpatient and post-hospital discharge mortality among acutely ill young children across a spectrum of nutritional status. Primary data were collected from household members of 20 purposively selected cohort children over 18 months through formal interviews (total n = 74), complemented by informal discussions and observations. Data were analysed using narrative and thematic approaches. Results: Treatment-seeking pathways were often long and complex, particularly for children diagnosed as severely malnourished. Family members' stories reveal that children's carers, usually mothers, navigate diverse challenges related to intersecting vulnerabilities at individual, household and facility levels. Specific challenges include the costs of treatment-seeking, confusing and conflicting messaging on appropriate care and nutrition, and poor continuity of care. Strong power inequities were observed between family members and health staff, with many mothers feeling blamed for their child's condition. Caregivers' agency, as demonstrated in decision-making and actions, often drew on the social support of others but was significantly constrained by their situation and broader structural drivers. Conclusion: To support children's care and recovery, health systems must be more responsive to the needs of families facing multiple and interacting vulnerabilities. Reducing incurred treatment costs, improving interpersonal quality of care, and strengthening continuity of care across facilities is essential. Promising interventions need to be co-designed with community representatives and health providers and carefully tested for unintended negative consequences and potential for sustainable scale-up. [ABSTRACT FROM AUTHOR]

Background: Child stunting, an indicator of chronic malnutrition, is a global public health problem. Malnutrition during pregnancy and the first 2 years of life undermines the survival, growth, and development of children. Exposure to fecal pathogens vis-à-vis inadequate water, sanitation, and hygiene (WASH) has been implicated in the etiology of child stunting, highlighting the need to integrate WASH with nutrition-sensitive interventions to comprehensively address this complex problem. The aim of this study was to describe a systematic, theoretically informed approach (that drew from the Starr and Fornoff approach to the Theory of Change development and the Behavior Change Wheel approach) to design a multi-component and integrated social and behavior change intervention to improve WASH and nutrition-related behaviors in western Kenya. Methods: This intervention was developed to be integrated into an existing project that utilized the care group model and aimed to create a culture of care and support for HIV/AIDS-affected children under two and their caregivers and was executed by local partners. We tested the newly created intervention packages in user-testing trials using an adapted Trials of Improved Practices approach to pilot acceptability and feasibility. Results: Using authentic stakeholder engagement and relevant theories, we conducted an 8-step process: (1) conduct mixed methods formative research, (2) prioritize target behaviors, (3) use causal analysis to create problem trees, (4) develop solution trees and articulate assumptions and rationales for change, (5) link solution trees to intervention functions, (6) develop the intervention plan, (7) create the intervention packages, and (8) test and refine the intervention packages. Conclusions: This study highlights the need to take a multi-sectorial, integrated approach that integrates contextually relevant behavior change theories with the experiential knowledge gleaned from stakeholders into the design of interventions that seek to reduce child stunting. This process resulted in the creation of intervention packages that grouped behaviors thematically to be most relevant and responsive to the population context. This work has the potential to make important contributions towards achievement of the United Nations' sustainable development goals. [ABSTRACT FROM AUTHOR]

Integrated nutrition and agricultural interventions have the potential to improve the efficiency and effectiveness of investments in food security and nutrition. This article aimed to estimate the costs of an integrated agriculture and health intervention (Mama SASHA) focused on the promotion of orange-fleshed sweet potato (OFSP) production and consumption in Western Kenya. Programme activities included nutrition education and distribution of vouchers for OFSP vines during antenatal care and postnatal care (PNC) visits. We used expenditures and activity-based costing to estimate the financial costs during programme implementation (2011-13). Cost data were collected from monthly expense reports and interviews with staff members from all implementing organizations. Financial costs totalled US$507 809 for the project period. Recruiting and retaining women over the duration of their pregnancy and postpartum period required significant resources. Mama SASHA reached 3281 pregnant women at a cost of US$155 per beneficiary. Including both pregnant women and infants who attended PNC services with their mothers, the cost was US$110 per beneficiary. Joint planning, co-ordination and training across sectors drove 27% of programme costs. This study found that the average cost per beneficiary to implement an integrated agriculture, health and nutrition programme was substantial. Planning and implementing less intensive integrated interventions may be possible, and economies of scale may reduce overall costs. Empirical estimates of costs by components are critical for future planning and scaling up of integrated programmes. [ABSTRACT FROM AUTHOR]

Objective: Dietary practices in Kenya often fail to provide adequate nutrition during the first 1000 days of life, from conception to 2 years of age. We developed and qualitatively assessed the acceptability of easy-to-use dietary tools consisting of a marked bowl, slotted spoon and illustrated counselling card to support appropriate dietary practices during pregnancy, exclusive breast-feeding and complementary feeding of children aged 6-24 months.Design: We conducted qualitative research to assess community acceptability and obtain feedback on the design of the dietary tools.Setting: This research took place in urban and rural communities in Western Kenya.Subjects: We conducted twelve focus group discussions with community members (mothers, husbands, mothers-in-law, community leaders) and five interviews with government nutritionists to assess acceptability and obtain recommendations on design and delivery of the tools. We conducted 24-28 d of user testing with fourteen pregnant women, fourteen breast-feeding women and thirty-two mothers with infants aged 6-18 months.Results: Tools were positively received by communities. Mothers perceived improvements in their own and their children's food intakes including quantity, frequency, consistency and diversity. Many attributed perceived own and child's weight gain and/or increased energy to tool use. A minority reported using the bowl for other activities (n 9) or not using the bowl due to food insecurity (n 5).Conclusions: Results suggest that such tools have the potential to positively impact maternal and child dietary practices. Future work should quantitatively assess the impact on diet and nutrition outcomes and the underlying behavioural domains associated with changes. [ABSTRACT FROM AUTHOR]

The Baby‐Friendly Community Initiative (BFCI) is an extension of the 10th step of the Ten Steps of Successful Breastfeeding and the Baby‐Friendly Hospital Initiative (BFHI) and provides continued breastfeeding support to communities upon facility discharge after birth. BFCI creates a comprehensive support system at the community level through the establishment of mother‐to‐mother and community support groups to improve breastfeeding. The Government of Kenya has prioritized community‐based programming in the country, including the development of the first national BFCI guidelines, which inform national and subnational level implementation. This paper describes the process of BFCI implementation within the Kenyan health system, as well as successes, challenges, and opportunities for integration of BFCI into health and other sectors. In Maternal and Child Survival Program (MCSP) and UNICEF areas, 685 community leaders were oriented to BFCI, 475 health providers trained, 249 support groups established, and 3,065 children 0–12 months of age reached (MCSP only). Though difficult to attribute to our programme, improvements in infant and young child feeding practices were observed from routine health data following the programme, with dramatic declines in prelacteal feeding (19% to 11%) in Kisumu County and (37.6% to 5.1%) in Migori County from 2016 to 2017. Improvements in initiation and exclusive breastfeeding in Migori were also noted—from 85.9% to 89.3% and 75.2% to 92.3%, respectively. Large gains in consumption of iron‐rich complementary foods were also seen (69.6% to 90.0% in Migori, 78% to 90.9% in Kisumu) as well as introduction of complementary foods (42.0–83.3% in Migori). Coverage for BFCI activities varied across counties, from 20% to 60% throughout programme implementation and were largely sustained 3 months postimplementation in Migori, whereas coverage declined in Kisumu. BFCI is a promising platform to integrate into other sectors, such as early child development, agriculture, and water, sanitation, and hygiene. [ABSTRACT FROM AUTHOR]

Poor infant and young child feeding (IYCF) practices are associated with linear growth faltering. Our objective was to evaluate the impact of a nutrition and water and sanitation for health intervention on three IYCF indicators—minimum dietary diversity (MDD), minimum meal frequency (MMF), and minimum acceptable diet (MAD) in Kenyan children. Households were randomized into one of eight groups: (a) active control; (b) passive control; (c) water quality (W); (d) sanitation (S); (e) handwashing (H); (f) combined Water, Sanitation, and Handwashing; (g) nutrition (N); and (h) combined WSH + N. In the N and WSH + N arms, community‐based promoters counselled households on optimal IYCF practices, and small‐quantity lipid‐based nutrient supplements (SQ‐LNS) were provided to children 6–24 months of age. Twelve months (Year 1) and 24 months (Year 2) after interventions began, enumerators surveyed mothers to ascertain IYCF practices. We made pairwise comparisons of each intervention arm versus the active control arm using log binomial models. In total, 3,652 caretakers were surveyed at Year 1 and 4,987 caretakers at Year 2. Compared with the active control, there were no differences in any of the arms in MDD, MMF, or MAD, aside from an increase in MDD at Year 1 in the nutrition only arm but not in the combined WSH + N arm (N: 68%; WSH + N: 61%; C: 61%; N arm prevalence ratio: 1.13 95% CI [1.01, 1.25]). In this setting, a nutrition behaviour change communication intervention had little impact on IYCF indicators. The provision of SQ‐LNS was not detrimental to current IYCF indicators in the community. [ABSTRACT FROM AUTHOR]