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Small-quantity lipid-based nutrient supplements (SQ-LNS) are designed to enrich maternal and child diets with the objective of preventing undernutrition during the first 1,000days. Scaling up the delivery of supplements such as SQ-LNS hinges on understanding private demand and creatively leveraging policy-relevant factors that might influence demand. We used longitudinal stated willingness-to-pay (WTP) data from contingent valuation studies that were integrated into randomized controlled nutrition trials in Ghana and Malawi to estimate private valuation of SQ-LNS during pregnancy, postpartum, and early childhood. We found that average stated WTP for a day's supply of SQ-LNS was more than twice as high in Ghana than Malawi, indicating that demand for SQ-LNS (and by extension, the options for effective delivery of SQ-LNS) may be very context specific. We also examined factors associated with WTP, including intervention group, household socioeconomic status, birth outcomes, child growth, and maternal and child morbidity. In both sites, WTP was consistently negatively associated with household food insecurity, indicating that subsidization might be needed to permit food insecure households to acquire SQ-LNS if it is made available for purchase. In Ghana, WTP was higher among heads of household than among mothers, which may be related to control over household resources. Personal experience using SQ-LNS was not associated with WTP in either site.

Small‐quantity lipid‐based nutrient supplements (SQ‐LNS) are designed to enrich maternal and child diets with the objective of preventing undernutrition during the first 1,000 days. Scaling up the delivery of supplements such as SQ‐LNS hinges on understanding private demand and creatively leveraging policy‐relevant factors that might influence demand. We used longitudinal stated willingness‐to‐pay (WTP) data from contingent valuation studies that were integrated into randomized controlled nutrition trials in Ghana and Malawi to estimate private valuation of SQ‐LNS during pregnancy, postpartum, and early childhood. We found that average stated WTP for a day's supply of SQ‐LNS was more than twice as high in Ghana than Malawi, indicating that demand for SQ‐LNS (and by extension, the options for effective delivery of SQ‐LNS) may be very context specific. We also examined factors associated with WTP, including intervention group, household socioeconomic status, birth outcomes, child growth, and maternal and child morbidity. In both sites, WTP was consistently negatively associated with household food insecurity, indicating that subsidization might be needed to permit food insecure households to acquire SQ‐LNS if it is made available for purchase. In Ghana, WTP was higher among heads of household than among mothers, which may be related to control over household resources. Personal experience using SQ‐LNS was not associated with WTP in either site.

International audience; Background: Dietary diversity is a key element of diet quality, but diets of women of reproductive age (WRA; aged 15–49 y) in resource-poor settings are often deficient in a range of micronutrients. Previous work showed associations between simple food-group diversity indicators (FGIs) and micronutrient adequacy among WRA. For operational and advocacy purposes, however, there is strong demand for a dichotomous indicator reflecting an acceptable level of dietary diversity.Objective: The aim of the study was to develop a dichotomous indicator of dietary diversity in WRA.Methods: We performed a secondary analysis of 9 data sets containing quantitative dietary data from WRA in resource-poor settings (total n = 4166). From the raw dietary data, we calculated an individual “mean probability of adequacy” (MPA) across 11 micronutrients. Several candidate FGIs were constructed. Indicator performance in predicting an MPA >0.60 was assessed within each data set by using receiver-operating characteristic analysis and sensitivity and specificity analysis at various FGI cutoffs. The analysis was performed separately for nonpregnant and nonlactating (NPNL) women and for lactating women.Results: We identified 2 “best candidate” dichotomous indicators on the basis of 9- or 10-point food-group scores (FGI-9 and FGI-10) with a cutoff of ≥5 food groups. Both were significantly correlated to MPA in each site (P < 0.001). Areas under the curve were moderate, ranging from 0.62 to 0.82 among NPNL women and from 0.56 to 0.90 among lactating women. Comparisons of results slightly favored FGI-10 for all women.Conclusions: When resource-intensive dietary methods are not feasible, a simple dichotomous indicator based on a cutoff of ≥5 of 10 defined food groups reflects “minimum dietary diversity for women of reproductive age.” According to the conclusions of a consensus meeting of experts, this indicator is well suited for population-level assessment, advocacy, and possibly also for tracking of change in dietary diversity across time.

Exclusive breastfeeding is recommended during the first 6 months of life; thereafter, continued breastfeeding along with nutritious complementary foods is recommended. Continued breastfeeding contributes a substantial proportion of nutrient needs and promotes healthy growth and development, but the quantity of breast milk consumed may be highly variable and little is known about the factors associated with breast milk intake after 6 months of age. The present study was conducted to assess factors associated with breast milk intake of Malawian infants at 9-10 months of age. Breast milk intake was measured using the dose-to-mother deuterium oxide dilution method in a subsample of 358 Malawian infants who were participating in a randomized controlled trial of lipid-based nutrient supplements. Regression analysis was used to assess associations between breast milk intake and several maternal and infant variables. Mean (standard deviation) breast milk intake was 752 (244) g day(-1) . In multiple regression, breast milk intake was positively associated with infant weight (+62 g per kg body weight, P

BackgroundChildhood stunting usually begins in utero and continues after birth; therefore, its reduction must involve actions across different stages of early life.ObjectiveWe evaluated the efficacy of small-quantity, lipid-based nutrient supplements (SQ-LNSs) provided during pregnancy, lactation, and infancy on attained size by 18 mo of age.DesignIn this partially double-blind, individually randomized trial, 1320 women at ≤20 wk of gestation received standard iron and folic acid (IFA group), multiple micronutrients (MMN group), or SQ-LNS (LNS group) daily until delivery, and then placebo, MMNs, or SQ-LNS, respectively, for 6 mo postpartum; infants in the LNS group received SQ-LNS formulated for infants from 6 to 18 mo of age (endline). The primary outcome was child length by 18 mo of age.ResultsAt endline, data were available for 85% of 1228 infants enrolled; overall mean length and length-for-age z score (LAZ) were 79.3 cm and -0.83, respectively, and 12% of the children were stunted (LAZ

Background Supplementing pregnant and lactating mothers with small quantity lipid-based nutrient supplements (SQ-LNS) has resulted in improvements in birth outcomes in some low-income settings. In order to be effective, SQ-LNS must be consumed regularly over sustained periods. Methods The objective was to assess and compare acceptability of and adherence to SQ-LNS consumption among pregnant and lactating women in Ghana and Malawi throughout 12 months of supplementation. We enrolled women before 20 gestation weeks into randomized trials in Ghana (n = 1320) and Malawi (n = 869). In the SQ-LNS group participants received a 20 g sachet of supplement per day during pregnancy and the first 6 months of lactation. In the control groups participants received multiple micronutrients (MMN) during pregnancy and lactation or iron and folic acid (IFA) during pregnancy and calcium during lactation. We used questionnaires to collect data on self-reported adherence to daily use of supplements and conducted in-depth interviews with women in the SQ-LNS group to examine acceptability. Results The mean self-reported adherence during the supplementation period was lower in Ghana (79.9 %) than in Malawi (91.7 %) for all supplements (difference 11.8 %, P

Women of reproductive age living in resource-poor settings are at high risk of inadequate micronutrient intakes when diets lack diversity and are dominated by staple foods. Yet comparative information on diet quality is scarce and quantitative data on nutrient intakes is expensive and difficult to gather. We assessed the potential of simple indicators of dietary diversity, such as could be generated from large household surveys, to serve as proxy indicators of micronutrient adequacy for population-level assessment. We used 5 existing data sets (from Burkina Faso, Mali, Mozambique, Bangladesh, and the Philippines) with repeat 24-h recalls to construct 8 candidate food group diversity indicators (FGI) and to calculate the mean probability of adequacy (MPA) for 11 micronutrients. FGI varied in food group disaggregation and in minimum consumption required for a food group to count. There were large gaps between intakes and requirements across a range of micronutrients in each site. All 8 FGI were correlated with MPA in all sites; regression analysis confirmed that associations remained when controlling for energy intake. Assessment of dichotomous indicators through receiver-operating characteristic analysis showed moderate predictive strength for the best choice indicators, which varied by site. Simple FGI hold promise as proxy indicators of micronutrient adequacy.

Chapter 6 / Implications for the Measurement of Child Feeding, Hygiene, and Caregiver–Child Interactions in Program and Survey

Summary indicators for measuring and assessing infant and child feeding practices are needed for research, communication and advocacy, and program evaluation. This paper reports on progress in developing a summary measure of infant and child feeding practices that addresses the following two challenges: infant and child feeding is multidimensional, and appropriate practices vary by age of the child. Much previous research in the area of infant and child feeding has focused on single practices over a narrow age range and so has not addressed the determinants and impact of adequate or optimal infant and child feeding. Using data from the Ethiopia Demographic and Health Survey, an infant and child feeding index is constructed, summarizing a range of key practices, including breastfeeding, bottle use, feeding frequency, and diet diversity. Because it provides age-specific scoring and incorporates various practices, the index is a useful analytic tool. The index is associated with an indicator of child growth (height-for-age) in bivariate and multivariate analyses. Examination of individual indicators shows that this association is driven by a strong positive association between one component "diet diversity" and height-for-age. Further work is required to establish the nature of the relationship between infant and child feeding indicators, nutrient adequacy, growth, and other outcomes. But because it can be used to illustrate the association between a set of recommended practices and growth, the index may serve as a communication tool with policymakers. Simulations show that the index accurately reflects an averaging of changes in individual component practices, and so it may also be of use to program managers who seek a summary measure for assessing program impact on a range of early feeding practices.

"Feeding practices are an important determinant of the nutritional status of infants and children. It is therefore useful to measure and describe infant and child feeding practices in a number of contexts. Such measurements could enable (1) international comparisons of the adequacy of infant and child feeding, (2) research linking infant and child feeding to determinants or outcomes, (3) advocacy regarding the importance of adequate infant and child feeding, and (4) monitoring and evaluation of interventions designed to change practices. This paper reports on progress in developing a summary measure of infant and child feeding practices—the infant and child feeding index (ICFI). The report also addresses two challenges in measuring child feeding practices, namely that infant and child feeding is multi-dimensional, and appropriate practices vary by age of the child. The authors refine the ICFI and confirm earlier findings that the ICFI is associated with child nutritional status. They also determine which components of the feeding index appear to be most important in driving its association with child nutritional status. Finally, they assess the potential usefulness of the index for the four purposes listed above." -from Authors' Abstract

This document summarizes findings from the Accra Urban Food and Nutrition Study (AUFNS) about the importance of care as an input to child nutrition and the relative contribution of various maternal and household resources to the provision of care. Findings from the quantitative survey (n = 556) and the in-depth observational study (n = 22) are reviewed and complemented with insights from the participatory rapid appraisals (PRAs) carried out at the onset of the study. Results of each phase of the research have been reported separately; this report aims to integrate findings from all three components. The key findings related to the five main questions addressed by this study are summarized as follows. ! Is care an important input into child nutrition in Accra? The Accra study provides unequivocal evidence of the critical role of childcare practices as a key input into children’s nutritional status. ! Which care practices seem to be most crucial for child nutrition? Findings from the observational study confirmed the suggestion from the quantitative survey that optimal feeding practices during the first 6 months of life contribute to the prevention of growth failure among young infants in Accra and that the benefits may linger beyond the first year of life. ! Which maternal and household resources contribute the most to enhancing care in Accra? Maternal education was the characteristic most strongly associated with good childcare practices. For the majority of women, employment did not seem to be a severe constraint for childcare and nutrition in this context. However, maternal early return to work after delivery—usually a response to economic constraints—may entail risks for children. ! What are the program and policy responses to promote optimal childcare practices in this urban context? Our findings support the universal consensus on the importance of investing in girls’ education. In the short term, effective nutrition education and behavior change strategies can simulate some of the benefits of formal education. Support for workingwomen in the form of low-cost, community-based childcare facilities should also be given priority, as well as policies to address poverty alleviation, income generation, hygiene and sanitation, and quality control of street food sales. ! How do the three research approaches used for the measurement of childcare complement each other? Each method provided unique information and also enriched and informed interpretation of other study components. The “triangulation” of findings also helped generate additional hypotheses that could be tested using an iterative process of analysis. This allowed for obtaining a richer and more complete picture of the role of care as an input into child nutrition in Accra.

The role of care as a critical influence on child nutrition, health, and development has received increasing attention in the last decade. While the role of care has been well elaborated at a conceptual level, we still lack simple, valid, and reliable tools to measure many aspects of care. In this review, experience with the measurement of selected childcare and feeding practices is summarized and implications for programs are discussed. Hygiene practices The use of interviews and recall methods is discouraged for the measurement of hygiene practices because research has shown that responses tend to be biased towards overreporting of “good” practices. Observational methods are therefore the method of choice, but they are subject to problems of reactivity—that is, that people behave differently in the presence of an observer—and normal day-to-day variability. Spot-check observations are an increasingly popular alternative, as they are less time consuming and costly and appear to be less reactive. However, like structured observations, they are subject to problems of day-to-day variability. Approaches to minimize biases and errors due to reactivity and day-to-day variability are discussed. Feeding practices Most feeding practice research has focused on the dietary aspects of feeding, and primarily on breastfeeding and complementary feeding. These practices are usually measured by maternal recall, but little evidence exists to document the reliability and validity of maternal recall of these practices. Recall errors may be particularly problematic when long recall periods are involved and when recall periods vary widely between respondents (e.g., when mothers of all children under 5 years of age are asked to recall early breastfeeding practices). Recall bias also may occur, especially following education interventions, when individuals are aware of what the “correct” answer is. Suggestions for reducing recall errors and biases in research and program contexts are discussed. Caregiver-child interactions during feeding The new focus on care in nutrition research has led to recognition of the importance of additional, nondietary aspects of child feeding, which include a variety of caregiver-child interactions. The importance of the role of poor appetite has also been highlighted. Interactions include responsive feeding, encouragement to eat, response to poor appetite, and adaptation of feeding to the child’s developmental stage. Structured observations have been the method of choice for measuring these interactions, and various measurement scales have been developed, though most of them have not yet been validated. There is very limited experience with survey approaches, and it is probable that many aspects of these interactions will never be amenable to survey approaches. Attempts to operationalize and measure child appetite have been successful, and the use of a simple visual appetite analogue scale appears promising. Additional considerations for programming and research ! There is evidence that good (or bad) practices tend to cluster, both within dimensions of care such as hygiene or feeding, and across dimensions. Also, it may be that a minimum number of good practices is necessary for health benefits to be obtained. For these reasons, composite indices or summary measures that combine various practices in one index may be useful. Additional research is needed to validate these indices. ! Program planning and design should be preceded by qualitative work in order to provide well-grounded and specific knowledge of practices, relevant norms, and potential constraints to adoption of optimal practices. In addition to guiding program design, this information should be used to inform selection of indicators and methods for monitoring and evaluation. ! Mixed methods, including both qualitative and quantitative approaches, are recommended at the planning stage, as well as in monitoring and evaluation stages, in order to maximize opportunities for triangulation of findings.

This document summarizes findings from the Accra Urban Food and Nutrition Study (AUFNS) about the importance of care as an input to child nutrition and the relative contribution of various maternal and household resources to the provision of care.