Search

The purpose of this study was to determine the local progression rate and identify factors that may predict local progression, in patients who achieve a complete response (CR) radiologically after undergoing transarterial chemoembolization (TACE) for hepatocellular carcinoma (HCC).One-hundred-forty-seven patients, who achieved CR of 224 HCCs after TACE, were retrospectively reviewed. There were 109 men and 38 women with a mean age of 61.6 ± 6.8 (SD) years (range: 45.4-86.9 years). Logistic mixed-effects and Cox regression models were used to evaluate associations between clinical factors and local progression.A total of 75 patients (75/147; 51%) and 99 (99/224,44.2%) lesions showed local progression at a median of 289.5 days (Q1: 125, Q3: 452; range: 51-2245 days). Pre-treatment, international normalization ratio (INR) (1.17 ± 0.15 [SD] vs. 1.25 ± 0.16 [SD]; P0.001), model for end-stage liver disease (9.4 ± 2.6 [SD] vs. 10.6 ± 3.2 [SD]; P = 0.010) and Child-Pugh score (6 ± 1 [SD] vs. 6.4 ± 1.3 [SD]; P = 0.012) were significantly lower while albumin serum level (3.4 ± 0.62 [SD] vs. 3.22 ± 0.52 [SD]; P = 0.033) was significantly greater in those who showed local progression as compared to those who did not. In terms of local-recurrence free survival, the number of TACE treatments (hazard ratio [HR]: 2.05 [95% CI: 1.57-2.67]; P0.001), INR (HR: 0.13 [95% CI: 0.03-0.61]; P = 0.010) and type of TACE (P = 0.003) were significant. Patients with local progression on any tumor did not differ from those who did in terms of overall survival (P = 0.072), however, were less likely to be transplanted (20/75, 26.7%) than those who did not (33/72; 36.1%) (P = 0.016).A significant number of patients who achieve CR of HCC after TACE have local progression. This emphasizes the importance of long-term follow up.

To determine the realized tumor to normal ratios (TNRs) in patients undergoing radiation segmentectomies (RS); determine the relationship between TNRs and particle load in transarterial radioembolization (TARE).In total, 148 patients who underwent 184 TARE procedures for hepatocellular carcinoma were evaluated. Post treatment SPECT CT bremsstrahlung imaging was analyzed utilizing Simplicit90y™ to determine realized TNR. A model which normalized activity across all RS treatments to a level that would achieve 400 Gy by unicompartmental dosing was created to determine the affect realized TNR would have on tumor absorbed dose.The mean TNR in the setting of RS was 2.88 ± 1.60 and was higher for glass as compared to resin microspheres (3.07 ± 1.68 vs 2.24 ± 1.21, p = 0.01). The TNR was significantly greater in the RS as compared to the lobar deliveries (2.88 ± 1.60 vs 2.16 ± 1.12, p 0.01). When normalizing the activity of RS treatments to the level required to achieve 400 Gy by unicompartmental calculations, there was found to be significant differences in the predicted tumor absorbed dose when separated by the median tumor dose (601.2 ± 133.3 vs 1146.9 ± 297.5, p 0.01) or median realized TNR (1119.2 ± 341 Gy vs 635.7 ± 160.2 Gy, p 0.01). Particle load was found to be associated with TNR on univariate (p 0.01) and multivariate (p 0.01) analysis.Significant TNRs are seen in RS and perhaps argue for the use of multi-compartmental dosimetry techniques in this setting and particle load may affect TNR.• Tumor to normal ratios were significantly higher in radiation segmentectomies than lobar deliveries. • Tumor to normal ratios were significantly higher when utilizing glass, as compared to resin microspheres. • When creating a model that prescribed the activity required to reach 400 Gy by MIRD, realized tumor dose varied significantly in radiation segmentectomies.

To determine the accuracy and clinical significance of planar scintigraphy lung shunt fraction (PLSF) and single-photon emission computerized tomography (SPECT) computed tomography (CT) lung shunt fraction (SLSF) before Y-90 transarterial radioembolization.Seventy patients (46 men, 24 women; mean age, 64 ± 9.5 [SD] years) who underwent 83 treatments with Y-90 transarterial radioembolization for primary or secondary malignancies of the liver with a PLSF ≥ 7.5% were retrospectively evaluated. The patients mapping technetium 99 m (Tc-99 m) macroaggregated albumin (MAA) PLSF and SLSF were calculated and compared to the post Y-90 delivery SLSF. A model using modern dose thresholds was created to identify patients who would require dose reduction due to a lung dose ≥ 30 Gy, with patients who required50% dose reduction considered to be delivery cancelations.A significant difference was found between mean PLSF (14.7 ± 11.6 [SD]%; range: 7.5-84.1%) and mean SLSF (8.7 ± 8.5 [SD]%; range: 1.7-73.5) (P0.001). The mean realized LSF (7.1 ± 3 [SD]%; range:1.5-17.6) was significantly less than the PLSF (P0.001) but not the SLSF (P = 0.07). PLSF significantly overestimated the realized LSF by more than the SLSF (8.5 ± 5.3 [SD] % [range: -0.1-21.7] vs. 0.8 ± 3.6 [SD] % [range: -5-13.2], respectively) (P0.001). Based on the clinical significance model, 20 patients (20/83, 24.1%) would have required dose reduction or cancelation when using PLSF but would not require even a dose reduction when using the SLSF. Significantly more deliveries would have been be canceled if PLSF was used as compared to SLSF (22/83 [26.5%] vs. 6/83 [7.2%], respectively) (P0.001).SLSF is significantly more accurate at predicting realized LSF than PLSF and this difference is of clinical significance in a number of patients with a PLSF ≥ 7.5%.

The purpose of this brief report was to retrospectively evaluate the safety and efficacy of cryoablation and compare the outcomes with those of percutaneous ethanol injection (PEI) for the treatment of metastatic cervical lymph nodes (CLNs) in patients with thyroid cancer at a single center. The study included 24 patients with 47 CLNs treated with PEI and 7 patients with 11 CLNs treated with cryoablation. Three of 7 (42.9%) patients did not respond to PEI and progressed to cryoablation. There were more local recurrences in CLNs treated with PEI (7/47, 14.9%) compared with cryoablation (0/11, 0%), but this did not reach significance (P = .33). There was no difference in mild/moderate (3/24, 12.5% vs 2/7, 28.6%; P = .31) or severe (1/24, 4.2% vs 0/7, 0%; P = 1) adverse events in the PEI and cryoablation cohorts. The number of treatments required for CLNs treated with PEI (2 ± 1.1) was significantly greater than those for CLNs treated with cryoablation (1 ± 0) (P = .002). These limited data suggest that the treatment of metastatic CLNs with cryoablation or PEI may be safe and effective; however, further data are needed.

To evaluate the correlation of neutrophil-to-lymphocyte ratio (NLR), platelet-to-lymphocyte ratio (PLR), aspartate aminotransferase-to-lymphocyte ratio (ALRI), systemic inflammation index (SII), and lymphocyte count to oncologic outcomes in metastatic colorectal cancer (mCRC) patients undergoing transarterial radioembolization (TARE).All patients undergoing TARE for mCRC were retrospectively reviewed at a single academic institution. A receiver operating characteristics (ROC) curve analysis was performed using a landmark survival point of 12 months, with an area under the curve (AUC) calculated. A cutoff point was determined by Youden's index and used to separate patients for OS and PFS analysis. Cox proportional-hazards models which included pertinent clinical factors were also created to evaluate PFS and OS.In total, 41 patients who underwent 66 TARE treatments were included. A correlation was seen between post-treatment ALRI 45 (HR: 0.38 (95%CI: 0.17-0.86), p = 0.02) and PFS. Patients with a pretreatment ALRI score 20 had a significantly longer OS (HR: 0.49 (95%CI: 0.19-0.88), p = 0.02) as did those with a post-treatment lymphocyte count 1.1 10Inflammatory markers may be associated with OS and PFS in mCRC patients undergoing TARE.

Shamar Young,1 Ranjan Ragulojan,1 Ting Chen,1 Joshua Owen,1 Donna D’souza,1 Tina Sanghvi,2 Jafar Golzarian,1 Siobhan Flanagan1 1University of Minnesota, Department of Radiology, Division of Interventional Radiology, Minneapolis, MN, 55455, USA; 2Minneapolis VA Medical Center, Department of Radiology, Minneapolis, MN, 55455, USACorrespondence: Shamar Young, Tel +1 612-624-6189, Email youn1862@umn.eduObjective: To evaluate the dynamic changes of lymphocytes following transarterial radioembolization (TARE) for hepatocellular carcinoma (HCC) and their relationship to normal liver dose (NLD).Materials and Methods: A total of 93 patients who underwent 102 treatments were retrospectively reviewed. Absolute lymphocyte counts pretreatment and at 1, 3, 6, and 12 months were evaluated. Kaplan–Meier, Spearman correlation, receiver operating characteristic (ROC) curve, and area under the curve (AUC) analyses were performed.Results: The mean absolute lymphocyte count at baseline was 1.25 ± 0.79 103/μL which was significantly greater than 1 (0.71 ± 0.47 103/μL, p< 0.0001), 3 (0.79 ± 0.77 103/μL, p=0.0003), and 6 (0.81 ± 0.44 103/μL, p=0.0001) months, but not significantly different than 12 (0.92 ± 0.8 103/μL, p=0.12) months post treatment. There was a modest negative correlation between NLD and lymphocyte count at 1 month (rho= − 0.216, p=0.03), which strengthened at 3 months post treatment (rho= − 0.342, p=0.008). AUC of ROC analysis between absolute lymphocyte count ≤ 1 103/μL or > 1 103/μL at 1, 3, 6, and 12 months post treatment was 0.625, 0.676, 0.560, and 0.794, respectively. Univariate analysis of overall survival when separating patients by a lymphocyte count of ≤ 1 103/μL and > 1 103/μL demonstrated a significant difference at 1 (HR: 0.56, 95% CI: 0.33– 0.95, p=0.03), 3 (HR: 0.41, 95% CI: 0.18– 0.94, p=0.035) and 6 (HR: 0.36, 95% CI: 0.17– 0.77, p=0.008) months post treatment, but not pretreatment or at 12 months.Conclusion: NLD may correlate with lymphocyte depression at 1 and 3 months and lymphopenia may portend a worse overall survival in the post treatment setting.Keywords: hepatocellular carcinoma, transarterial radioembolization, lymphocytes

Antenatal care (ANC) is the largest health platform globally for delivering maternal nutrition interventions (MNIs) to pregnant women. Yet, large missed opportunities remain in nutrition service delivery. This paper examines how well evidence-based MNIs were incorporated in national policies and programs in Bangladesh, Burkina Faso, Ethiopia and India. We compared the nutrition content of ANC protocols against global recommendations. We used survey data to elucidate the coverage of micronutrient supplementation, weight gain monitoring, dietary and breastfeeding counselling. We reviewed literature, formative research and program assessments to identify barriers and enabling factors of service provision and maternal nutrition practices. Nutrition information in national policies and protocols was often fragmented, incomplete and did not consistently follow global recommendations. Nationally representative data on MNIs in ANC was inadequate, except for iron and folic acid supplementation. Coverage data from subnational surveys showed similar patterns of strengths and weaknesses. MNI coverage was consistently lower than ANC coverage with the lowest coverage of weight gain monitoring and variable coverage of dietary and breastfeeding counselling. Key common factors associated with coverage were micronutrient supply disruptions; suboptimal counselling on maternal diet, weight gain, and breastfeeding; and limited or no record keeping. Adherence of women to micronutrient supplementation and dietary recommendations was low and associated with late and too few ANC contacts, poor maternal knowledge and self-efficacy, and insufficient family and community support. Models of comprehensive nutrition protocols and health systems that deliver maternal nutrition services in ANC are urgently needed along with national data systems to track progress.

Suboptimal dietary intake is a critical cause of poor maternal nutrition, with several adverse consequences both for mothers and for their children. This study aimed to (1) assess maternal dietary patterns in India, (2) examine enablers and barriers in adopting recommended diets, (3) review current policy and program strategies to improve dietary intakes. We used mixed methods, including empirical analysis, compiling data from available national and subnational surveys, and reviewing literature, policy, and program strategies. Diets among pregnant women are characterized by low energy, macronutrient imbalance, and inadequate micronutrient intake. Supply- and demand-side constraints to healthy diets include food unavailability, poor economic situation, low exposure to nutrition counselling, food restrictions and taboos, adverse family influence and gender norms, and gaps in knowledge. Intervention strategies with potential to improve maternal diets include food-based programs, behavior change communication, and nutrition-sensitive agriculture interventions. However, strategies face implementation bottlenecks and limited effectiveness in real-world at-scale impact evaluations. In conclusion, investments in systems approaches spanning health, nutrition, and agriculture sectors, with evaluation frameworks at subnational levels, are needed to promote healthy diets for women.

To evaluate the ability of neutrophil-to-lymphocyte ratio (NLR), platelet-to-lymphocyte ratio (PLR), aspartate aminotransferase-to-lymphocyte ratio (ALRI) and systemic-inflammation index (SII) to predict clinical outcomes in hepatocellular carcinoma (HCC) patients undergoing transarterial radioembolization (TARE).One hundred forty-five patients who underwent treatment of 167 HCCs had their pretreatment and 1 month post treatment laboratory values evaluated. Overall survival (OS), progression-free survival (PFS) and local PFS models were performed with patients separated by median inflammatory scores.The median pretreatment NLR, PLR, ALRI and SII were 3.0 (range: 0.5-176), 104.4 (range: 25-830), 55.7 (range: 7.5-2090) and 360.2 (range: 51.1-7207.8), respectively. While the median post treatment NLR, PLR, ALRI and SII were 6.2 (range: 0.4-176), 180 (range: 35-2100), 125 (range: 15.9-5710) and 596.8 (range: 28.9-19,320), respectively. OS models showed significant differences when separating the groups by median post treatment NLR (p = 0.003) and SII (p = 0.003). Multivariate Cox regression models for OS with all pre and post treatment inflammatory markers (log-scale) as well as tumor size, AFP and Child-Pugh score showed significant pretreatment NLR [HR: 0.22 (95% CI:0.06-0.75), p = 0.016] and SII [3.52 (95% CI: 1.01-12.3), p = 0.048], as well as post treatment NLR [6.54 (95% CI: 1.57-27.2), p = 0.010] and SII [0.20 (95% CI: 0.05-0.82), p = 0.025] association. The post treatment ALRI (p = 0.010) correlated with PFS while, post treatment NLR (p 0.001), ALRI (p = 0.024) and SII (p = 0.005) correlated with local PFS.Pretreatment and post treatment NLR and SII may be associated with OS and post treatment ALRI may be associated with both PFS and local PFS in HCC patients undergoing TARE.

Background Interaction within mothers’ social networks can theoretically diffuse messages from interventions and campaigns into norms and practices for infant and young child feeding (IYCF). Objectives We hypothesized that mothers’ social networks, diffusion of information, and social norms differed in intensive [intensive interpersonal counseling (IPC), community mobilization (CM), and mass media (MM)] compared with nonintensive (standard IPC and less-intensive CM and MM) intervention areas, were associated with IYCF practices, and partly explained practice improvement. Methods We conducted household surveys at endline in 2014 and follow-up in 2016 (n = ∼2000 each round). We used multiple regression to test differences and changes in networks, diffusion, and norms within intervention areas. We analyzed paths from intervention exposure to IYCF practices through networks, diffusion, and norms. Results Mothers’ networks were larger in intensive than in nonintensive areas in 2014 and increased in both areas over time [25–38 percentage points (pp)]. The prevalence of receipt of IYCF information was high, with no changes over time in intensive areas but an increase in nonintensive areas (8–16 pp). In both areas, more family members and health workers provided IYCF information over time. Sharing of information increased 17–23 pp in intensive and 11–41 pp in nonintensive areas over time. Perceived descriptive norms improved 8–16 pp in intensive and 17–28 pp in nonintensive areas. Perceived injunctive norms were high in both areas. Breastfeeding practices were associated with networks, diffusion, and norms (OR: 1.6–4.4 times larger comparing highest with lowest quartile). Minimum dietary diversity was associated with larger networks and diffusion (OR: 1.5–2.2) but not with social norms. Indirect paths from intervention exposure to practices explained 34–78% of total effects. Conclusions Diffusion of IYCF information through social networks, reinforced by positive social norms for messages promoted over time, will contribute to positive changes in IYCF practices that may be achieved and sustained through large-scale social and behavior change interventions. This trial was registered at clinicaltrials.gov as NCT0274084.

Introduction Malnutrition in infancy contributes to high mortality and morbidity. In India, government has established nutrition rehabilitation centres for managing children with severe acute malnutrition. The study was conducted with aim to understand how community perceived malnutrition and how child's size at birth, infant and young child feeding related behaviours and child's illness were associated with decline in the child's growth or health. Methods Qualitative research employing focused ethnographic methodologies was used. From February–December 2016, cases studies and in-depth interviews were conducted with 12 mothers of malnourished children Results Grounded on experience of participants, emerging themes were that importance of exclusive breastfeeding was neither understood nor emphasized, there was no concept of complementary feeding, family food lacked diversity, malnutrition was not recognised as a health hazard, and there was lack of autonomy of females in reproductive and general health issues. Conclusion Given these paths to malnutrition in infancy, there is an urgent need to create community awareness about malnutrition as a disease as well as about optimal breastfeeding and complementary feeding practices in infancy by using innovative behaviour change communication strategies.

OBJECTIVES: In Ethiopia, where 40% of the population is under 15 years, evidence on adolescent nutrition is limited. We examined the dietary diversity and its determinants among in-school adolescent girls in 2 regions in southern Ethiopia. METHODS: We used household survey data from 162 in-school adolescent girls aged 10–14 y across 54 primary schools in one agrarian region (SNNP) and one pastoralist region (Somali), collected in October-November 2019. Multiple regression models were used to examine factors such as nutrition knowledge, food availability and food insecurity associated with the dietary diversity score, adjusted for age and geographic clustering. RESULTS: All of the adolescent girls were currently enrolled in school (grades 4–8), and most resided with their mothers (96.9%) and fathers (80.2%). Prevalence of thinness was 11.7% (body mass index (BMI)-for-age Z-score < −2SD), and 35.2% were mildly thin (BMI-for-age Z-score < -1SD). Dietary diversity was low, with 3.7 food groups (out of 10) consumed in the last 24 h. Also, 48.8% reported consuming sweets and sugar-sweetened beverages in the last 24 h. Nutrition knowledge among adolescents was moderate, with an average score of 4.8 out of 8 knowledge items. On occurrences of food insecurity in the past 30 days, they reported an average score of 1.1 (out of 9 items). However, household surveys revealed a high degree of food insecurity (56.2%). Adolescents also reported that only 3.6 food groups (out of 10) were available at home some/most/all of the time (that is, 3–7 days) over the past 7 days. Unsurprisingly, food availability at home (β = 0.30, P = 0.000) and food insecurity (β = −0.12, P = 0.013) followed by nutrition knowledge (β = 0.11, 0 = 0.031) were significantly associated with dietary diversity score. CONCLUSIONS: Understanding the factors influencing poor diets among adolescents will help to enhance the design of educational interventions to improve adolescent nutrition outcomes, a critical priority in Ethiopia. However, household food insecurity and household food availability are serious concerns in this context. FUNDING SOURCES: Bill & Melinda Gates Foundation, through Alive & Thrive, managed by FHI 360; and CGIAR Research Program on Agriculture for Nutrition and Health (A4NH), led by the International Food Policy Research Institute.

Background Diarrhea prevalence increases from around the time that complementary foods are introduced. Improving caregiver’s hand hygiene during food preparation could reduce complementary food contamination and enteric pathogen transmission. Washing hands with soap is more common when water and soap are together at a convenient location. We conducted a three-month pilot intervention to evaluate two options for setting up handwashing stations: i) provide a handwashing station, or ii) help the family to make their own from available materials. Additionally, we assessed the feasibility of this intervention to be integrated with a child feeding program. Methods We conducted the intervention among two groups; 40 households received a free of cost handwashing station and another 40 households were motivated to place their own soap/soapy-water and water vessel near the food preparation and child feeding area. Community health workers encouraged caregivers to wash hands with soap/soapy-water before food preparation and feeding a child. They either assisted study participants to install the study-provided handwashing station at the recommended place or encouraged caregivers to develop their own. Field researchers assessed placement and composition of handwashing stations and the feasibility of integrating handwashing and nutrition messages. Results By end of the trial, 39/40 households developed their own handwashing station, comprising a bucket, mug and bar soap/soapy-water of which 60% (6/10) households were observed with a functional and complete handwashing station set. Observed handwashing with soap was detected among 8/10 households from the study-provided handwashing station group and 5/10 among households who had made their own handwashing station. Sixty-seven of the 76 caregivers recalled integrated intervention messages on social and health benefits of infant and young child feeding correctly; and all recalled key handwashing with soap times, before food preparation and feeding a child. Conclusion Encouraging households to develop their own handwashing station with soap and water to place at a food preparation/child feeding location is feasible over the short term. In the absence of large-scale provision of handwashing stations, caregivers can be encouraged to create and use their own. Integrating handwashing with soap into a nutrition intervention was feasible and acceptable and should be considered by policy makers.

Background Maternal morbidity is common in Bangladesh, where the maternal mortality rate has plateaued over the last 6 years. Maternal undernutrition and micronutrient deficiencies contribute to morbidity, but few interventions have measured maternal outcomes. We compared reported prevalence of antepartum, intrapartum, and postpartum complications among recently delivered women between maternal nutrition intervention and control areas in Bangladesh. Methods and findings We conducted a cross-sectional assessment nested within a population-based cluster-randomized trial comparing a nutrition counseling and micronutrient supplement intervention integrated within a structured home-based maternal, newborn, and child health (MNCH) program to the MNCH program alone in 10 sub-districts each across 4 Bangladesh districts. Eligible consenting women, delivering within 42–60 days of enrollment and identified by community-level health workers, completed an interviewer-administered questionnaire detailing the index pregnancy and delivery and allowed review of their home-based care register. We compared pooled and specific reported antepartum, intrapartum, and postpartum complications between study groups using hierarchical logistic regression. There were 594 women in the intervention group and 506 in the control group; overall, mean age was 24 years, 31% were primiparas, and 39% reported facility-based delivery, with no significant difference by study group. There were no significant differences between the intervention and control groups in household-level characteristics, including reported mean monthly income (intervention, 6,552 taka, versus control, 6,017 taka; p = 0.48), having electricity (69.6% versus 71.4%, p = 0.84), and television ownership (41.1% versus 38.7%, p = 0.81). Women in the intervention group had higher recorded iron and folic acid and calcium supplement consumption and mean dietary diversity scores, but reported anemia rates were similar between the 2 groups (5.7%, intervention; 6.5%, control; p = 0.83). Reported antepartum (69.4%, intervention; 79.2%, control; p = 0.12) and intrapartum (41.4%, intervention; 48.5%, control; p = 0.18) complication rates were high and not significantly different between groups. Reported postpartum complications were significantly lower among women in the intervention group than the control group (33.5% versus 48.2%, p = 0.02), and this difference persisted in adjusted analysis (adjusted odds ratio [AOR] = 0.51, 95% CI 0.32–0.82; p < 0.001). For specific conditions, odds of retained placenta (AOR = 0.35, 95% CI 0.19–0.67; p = 0.001), postpartum bleeding (AOR = 0.37, 95% CI 0.15–0.92; p = 0.033), and postpartum fever/infection (AOR = 0.27, 95% CI 0.11–0.65; p = 0.001) were significantly lower in the intervention group in adjusted analysis. There were no significant differences in reported hospitalization for antepartum (49.8% versus 45.1%, p = 0.37), intrapartum (69.9% versus 59.8%, p = 0.18), or postpartum (36.1% versus 29.9%, p = 0.49) complications between the intervention and control groups. The main limitations of this study are outcome measures based on participant report, non-probabilistic selection of community-level workers’ catchment areas for sampling, some missing data for variables derived from secondary sources (e.g., dietary diversity score), and possible recall bias for reported dietary intake and supplement use. Conclusions Reported overall postpartum and specific intrapartum and postpartum complications were significantly lower for women in intervention areas than control areas, despite similar rates of facility-based delivery and hospitalization for reported complications, in this exploratory analysis. Maternal nutrition interventions providing intensive counseling and micronutrient supplements may reduce some pregnancy complications or impact women’s ability to accurately recognize complications, but more rigorous evaluation is needed for these outcomes., Catherine Todd and colleagues reveal that nutritional education and micronutrient supplements can reduce intrapartum and postpartum complications in pregnant women in Bangladesh., Author summary Why was this study done? Adequate nutrition during pregnancy reduces risks of poor infant outcomes, like low birthweight, but there is relatively little information about whether nutrition is linked to reducing a woman’s risk of pregnancy complications. Maternal nutrition interventions starting during pregnancy are being implemented at scale in multiple settings, including in Bangladesh, and determining whether these interventions reduce maternal complications may strengthen efforts to implement similar interventions to optimize maternal and newborn health. What did the researchers do and find? At the time of the endline evaluation for the parent trial—which compared an intervention of home-based intensive maternal nutrition counseling and iron and calcium supplement provision combined with home-based antenatal care to home-based antenatal care alone—we interviewed women who had delivered within the last 60 days to inquire about complications during pregnancy, during delivery, and after delivery. This study included 594 women in the intervention group and 506 in the control group across 4 districts in Bangladesh; women in the 2 groups were similar with regard to number of prior pregnancies, age, and household assets. Reported complication rates during pregnancy or during delivery were somewhat lower among women from intervention areas, while reported complications after delivery were significantly lower among women from intervention areas, compared to those from control areas. What do these findings mean? Differences in reported complication rates may be due to actual differing levels resulting from intervention exposure, or to different perceptions of what conditions constitute pregnancy complications, which could also result from intervention exposure. The intervention did not appear to impact care-seeking during pregnancy or during labor based on similar skilled/facility-based care statistics for the intervention and control groups. Community-based care providers recorded key obstetric events accurately and at high rates, but greater understanding of client and provider perceptions regarding what constitutes maternal complications and ensuring provision of appropriate care are needed. Given the cross-sectional nature of the study and that complications were self-reported, the findings should be interpreted with caution.

Background:Diet diversity of pregnant women is associated with nutrition sufficiency, micronutrient adequacy, and pregnancy outcomes. However, the sociodemographic determinants of diet diversity among pregnant women in low-income countries are not well studied.Objective:The analysis was undertaken to study the determinants of high dietary diversity and consumption of micronutrient-rich foods by pregnant women from rural Bangladesh.Methods:Pregnant women (508) were randomly selected from southwestern Bangladesh and interviewed to collect data about diet and sociodemographic characteristics. A 24-hour recall was used to collect information about diet. Diet diversity score was calculated for 9 major food groups. All analyses were conducted using STATA SE 12.Result:The overall mean diet diversity score was low at 4.28 and was significantly high among pregnant women who have higher educational achievement, whose husbands’ occupation was business, who live in households of 4 or more family members, and who were dwelling in a house with more than 1 room. Highest gap on knowledge and consumption was reported for 3 food groups including dairy foods, eggs, and dark green leafy vegetables. Consumption of dairy and eggs was lower among women from low socioeconomic status, but no significant association was found between sociodemographic characteristics and consumption of leafy vegetables.Conclusion:Our analysis has shown that diet quality of pregnant women was poor and intake of micronutrient-rich foods was low despite having knowledge about the importance of these foods, underscoring the need for promoting the diet quality in developing countries through behavior change communication programs.

Understanding implementation of interventions is critical to illuminate if, how, and why the interventions achieve impact. Alive & Thrive integrated a nutrition intervention into an existing maternal, neonatal, and child health (MNCH) programme in Bangladesh, documenting improvements in women's micronutrient supplement intake and dietary diversity. Here, we examined how well the nutrition intervention was implemented and which elements of implementation explained intervention impact. Survey data were collected in 2015 and 2016 from frontline health workers (FLW) and households in areas randomized to nutrition‐focused MNCH (intensified interpersonal counselling, community mobilization, distribution of free micronutrient supplements, and weight‐gain monitoring) or standard MNCH (antenatal care with standard nutrition counselling). Seven intervention elements were measured: time commitment, training quality, knowledge, coverage, counselling quality, supervision, and incentives. Multiple regression was used to derive difference‐in‐differences (DID) estimates. Using village‐level endline data, path analysis was used to determine which elements most explained intervention impacts. FLWs in both areas were highly committed and well supervised. Coverage was high (>90%) for counselling, supplement provision, and weight‐gain monitoring. Improvements were significantly greater for nutrition‐focused MNCH, versus standard MNCH, for training quality (DID: 2.42 points of 10), knowledge (DID: 1.20 points), delivery coverage (DID: 4.16 points), and counselling quality (DID: 1.60 points). Impact was substantially explained by coverage and delivery quality. In conclusion, integration nutrition intervention into the MNCH programme was feasible and well‐implemented. Although differences in coverage and counselling quality most explained impacts, all intervention elements—particularly FLW training and performance—were likely important to achieving impact.

Improving infant and young child feeding practices is critical for improving growth and reducing child mortality and morbidity. This paper aims to compare predictors of minimum dietary diversity, an important indicator of adequate complementary feeding practices, in Bangladesh in 2011 and 2014. The 2011 and 2014 Bangladesh Demographic and Health Survey were used to examine predictors of minimum dietary diversity among 6-23 months. An additional analysis was conducted for the 18-23-month group, because a significant increase in meeting minimum dietary diversity recommendations was seen in this age group only. Factors found to be associated with practices were compared across time points. In 2011, minimum dietary diversity was 23.8% and increased to 28.8% in 2014. Among children 18-23 months, in 2011, minimum dietary diversity was 32.5% and increased to 42.8% in 2014. Among all children, wealth, education, exposure to media, and antenatal care were significant predictors of dietary diversity. In the 18-23-month age group, significant predictors in 2011 were wealth and decision making. In 2014, significant predictors were education and exposure to media. Demographic trends indicated a significant increase in education and exposure to media between 2011 and 2014. As these were significant for minimum dietary diversity in 2014 overall and for 18-23 months, they might be important targets of future interventions, specifically utilizing media channels and tailoring special strategies for women with low education and limited exposure to media.

Background: Maternal undernutrition is a major concern globally, contributing to poor birth outcomes. Limited evidence exists on delivering multiple interventions for maternal nutrition simultaneously. Alive & Thrive addressed this gap by integrating nutrition-focused interpersonal counseling, community mobilization, distribution of free micronutrient supplements, and weight-gain monitoring through an existing Maternal, Neonatal, and Child Health (MNCH) program in Bangladesh. Objectives: We evaluated the effect of providing nutrition-focused MNCH compared with standard MNCH (antenatal care with standard nutrition counseling) on coverage of nutrition interventions, maternal dietary diversity, micronutrient supplement intake, and early breastfeeding practices. Methods: We used a cluster-randomized design with cross-sectional surveys at baseline (2015) and endline (2016) (n ∼ 300 and 1000 pregnant or recently delivered women, respectively, per survey round). We derived difference-in-difference effect estimates, adjusted for geographic clustering and infant age and sex. Results: Coverage of interpersonal counseling was high; >90% of women in the nutrition-focused MNCH group were visited at home by health workers for maternal nutrition and breastfeeding counseling. The coverage of community mobilization activities was ∼50%. Improvements were significantly greater in the nutrition-focused MNCH group than in the standard MNCH group for consumption of iron and folic acid [effect: 9.8 percentage points (pp); 46 tablets] and calcium supplements (effect: 12.8 pp; 50 tablets). Significant impacts were observed for the number of food groups consumed (effect: 1.6 food groups), percentage of women who consumed ≥5 food groups/d (effect: 30.0 pp), and daily intakes of several micronutrients. A significant impact was also observed for exclusive breastfeeding (EBF; effect: 31 pp) but not for early initiation of breastfeeding. Conclusions: Addressing nutrition during pregnancy by delivering interpersonal counseling and community mobilization, providing free supplements, and ensuring weight-gain monitoring through an existing MNCH program improved maternal dietary diversity, micronutrient supplement consumption, and EBF practices. This trial was registered at clinicaltrials.gov as NCT02745249.

Background Improving and sustaining infant and young child feeding (IYCF) practices requires multiple interventions reaching diverse target groups over a sustained period of time. These interventions, together with improved maternal nutrition, are the cornerstones for realizing a lifetime of benefits from investing in nutrition during the 1000 day period. Objective Summarize major lessons from Alive & Thrive's work to improve IYCF in three diverse settings—Bangladesh, Ethiopia, and Vietnam. Methods Draw lessons from reports, studies, surveys, routine monitoring, and discussions on the drivers of successful design and implementation of IYCF strategies. Results Teaming up with carefully selected implementing partners with strong commitment is a critical first step. As programs move to implementation at scale, strategic systems strengthening is needed to avoid operational bottlenecks. Performance of adequate IYCF counseling takes more than training; it requires rational task allocation, substantial follow up, and recognition of frontline workers. Investing in community demand for IYCF services should be prioritized, specifically through social mobilization and relevant media for multiple audiences. Design of behavior change communication and its implementation must be flexible and responsive to shifts in society's use of media and other social changes. Private sector creative agencies and media companies are well equipped to market IYCF. Scaling up core IYCF interventions and maintaining quality are facilitated by national-level coordinating and information exchange mechanisms using evidence on quality and coverage. Conclusions It is possible to deliver quality IYCF interventions at scale, while creating new knowledge, tools, and approaches that can be adapted by others and contribute to accelerated scale up of IYCF programs globally.

Background Alive & Thrive aims to increase exclusive breastfeeding and complementary feeding practices in Bangladesh, Ethiopia, and Vietnam. Objective To develop and execute comprehensive communication strategies adapted to each context. Methods We documented how three countries followed an established iterative planning process, with research steps followed by key decisions, to develop a communication strategy in each country. Secondary analysis and formative research identified the priority practices to focus on, and locally specific constraints to proper infant and young child feeding (IYCF). Communication strategies were then developed based on the social, cultural, economic, epidemiological, media use, and programmatic contexts of each country. Results There were widespread gaps between recommended and actual feeding practices, and these varied by country. Gaps were identified in household, community, and institutional levels of awareness and skills. Strategies were designed that would enable mothers in each specific setting to adopt practices. To improve priority behaviors, messaging and media strategies addressed the most salient behavioral determinants through face-to-face communication, social mobilization, and mass media. Trials of improved practices (TIPs), concept testing, and pretesting of materials proved useful to verify the relevance and likely effectiveness of communication messages and materials tailored for different audiences in each setting. Coordination and collaboration with multiple stakeholders from the start was important to harmonize messages and approaches, expand geographic coverage to national scale, and sustain the interventions. Conclusions Our experience with designing largescale communication strategies for behavior change confirms that systematic analysis and local planning cannot be omitted from the critical process of strategic design tailored to each context. Multiple communication channels matched to media habits in each setting can reach a substantial proportion of mothers and others who influence their IYCF practices. Preliminary data suggest that exposure to mass media plays a critical role in rapidly reaching mothers, household members, community influentials, and health workers on a large scale. Combining face-to-face interventions for mothers with social mobilization and mass media was effective in improving IYCF practices.

Background Despite the existence of a strong evidence base for investing in infant and young child feeding (IYCF), sufficiently supported IYCF policies and programs are rare. Objective To develop evidence-based advocacy strategies in Bangladesh, Ethiopia, and Vietnam to enable policy change and to increase investments in and ensure scale-up and sustainability of IYCF programs. Methods Situational analysis, formative and opinion leader research, and stakeholder consultations were used to develop three contextualized advocacy strategies. Results Data were used to determine how IYCF was perceived and prioritized, identify opinion leaders and partners, identify barriers to and opportunities for strengthening commitment, and select messages, materials, and communication channels. Opinion leader research showed that malnutrition was a concern but not a priority for policy action. Where food security was an issue, poverty reduction strategies rather than IYCF programs were viewed as the solution. Few opinion leaders were aware of the importance of the first 1,000 days of life. In addition to policy gaps, awareness and implementation of existing policies were limited. This was often complicated by intragovernment conflicts and perspectives. Advocacy messages needed to be evidence based and delivered by credible champions. Engaging medical associations and the media presented an opportunity rarely leveraged in IYCF advocacy. Conclusions Although sociopolitical contexts may vary, awareness of the importance of IYCF is an overarching advocacy challenge. Consequently, investments in IYCF programs and policies lag. Evidence-based advocacy design has a potential for impact on national policies, investments, and commitment to implementation and should be used more widely to inform program design.

Promoting adequate nutrition through interventions to improve infant and young child feeding (IYCF) has the potential to contribute to child development.We examined whether an intensive intervention package that was aimed at improving IYCF at scale through the AliveThrive initiative in Bangladesh also advanced language and gross motor development, and whether advancements in language and gross motor development were explained through improved complementary feeding.A cluster-randomized design compared 2 intervention packages: intensive interpersonal counseling on IYCF, mass media campaign, and community mobilization (intensive) compared with usual nutrition counseling and mass media campaign (nonintensive). Twenty subdistricts were randomly assigned to receive either the intensive or the nonintensive intervention. Household surveys were conducted at baseline (2010) and at endline (2014) in the same communities (n = ∼4000 children aged 0-47.9 mo for each round). Child development was measured by asking mothers if their child had reached each of multiple milestones, with some observed. Linear regression accounting for clustering was used to derive difference-in-differences (DID) impact estimates, and path analysis was used to examine developmental advancement through indicators of improved IYCF and other factors.The DID in language development between intensive and nonintensive groups was 1.05 milestones (P = 0.001) among children aged 6-23.9 mo and 0.76 milestones (P = 0.038) among children aged 24-47.9 mo. For gross motor development, the DID was 0.85 milestones (P = 0.035) among children aged 6-23.9 mo. The differences observed corresponded to age- and sex-adjusted effect sizes of 0.35 for language and 0.23 for gross motor development. Developmental advancement at 6-23.9 mo was partially explained through improved minimum dietary diversity and the consumption of iron-rich food.Intensive IYCF intervention differentially advanced language and gross motor development, which was partially explained through improved complementary feeding. Measuring a diverse set of child outcomes, including functional outcomes such as child development, is important when evaluating integrated nutrition programs. This trial was registered at clinicaltrials.gov as NCT01678716.

Background Child undernutrition remains high in South Asian and sub-Saharan African countries. Rapid declines in nutritional status occur before the age of 2 years, particularly during the period of complementary feeding. Improving complementary feeding practices is a neglected area in nutrition programs. Objective To understand community perspectives on complementary feeding practices in order to inform the design of future interventions for improved complementary feeding. Methods From May through August 2009, data were collected in two rural locations and one urban location in Bangladesh through semistructured interviews, food attributes exercises, 24-hour dietary recalls, opportunistic observations, and trials of improved practices (TIPs). Key informant interviews and focus group discussions were also carried out among family members and community opinion leaders. Results Lay perceptions about complementary feeding differ substantially from international complementary feeding recommendations. A large proportion of children do not consume sufficient amounts of complementary foods to meet their energy and micronutrient needs. There was a gap in knowledge about appropriate complementary foods in terms of quality and quantity and strategies to convert family foods to make them suitable for children. Complementary feeding advice from family members, peers, and health workers, the importance given to feeding young children, and time spent by caregivers in feeding influenced the timing, frequency, types of food given, and ways in which complementary feeding occurred. Conclusions Perceptions and practices related to complementary feeding need to be effectively addressed to improve the levels of child undernutrition. Lack of understanding of children's nutritional needs and insufficient time for feeding children are key barriers to complementary feeding.

The Alive & Thrive programme scaled up infant and young child feeding interventions in Bangladesh from 2010 to 2014. In all, 8.5 million mothers benefited. Approaches – including improved counselling by frontline health workers during home visits; community mobilization; mass media campaigns reaching mothers, fathers and opinion leaders; and policy advocacy – led to rapid and significant improvements in key practices related to breastfeeding and complementary feeding. (Evaluation results are forthcoming.) Intervention design was based on extensive formative research and behaviour change theory and principles and was tailored to the local context. The programme focused on small, achievable actions for key audience segments identified through rigorous testing. Promotion strategies took into account underlying behavioural determinants and reached a high per cent of the priority groups through repeated contacts. Community volunteers received monetary incentives for mothers in their areas who practised recommended behaviours. Programme monitoring, midterm surveys and additional small studies to answer questions led to ongoing adjustments. Scale‐up was achieved through streamlining of tools and strategies, government branding, phased expansion through BRAC – a local non‐governmental implementing partner with an extensive community‐based platform – and nationwide mainstreaming through multiple non‐governmental organization and government programmes. Key messages Well‐designed and well‐implemented large‐scale interventions that combine interpersonal counselling, community mobilization, advocacy, mass communication and strategic use of data have great potential to improve IYCF practices rapidly.Formative research and ongoing studies are essential to tailor strategies to the local context and to the perspectives of mothers, family members, influential community members and policymakers. Continued use of data to adjust programme elements is also central to the process.Scale‐up can be facilitated through strategic selection of partners with existing community‐based platforms and through mass media, where a high proportion of the target audience can be reached through communication channels such as broadcast media.Sustaining the impacts will involve commitments from government and capacity building. The next step for capacity building would involve understanding barriers and constraints and then coming up with appropriate strategies to address them. One of the limitations we experienced was rapid transition of staff in key positions of implementing agencies, in government leadership, donors and other stakeholders. There was a need for continued advocacy, orientation and teaching related to strategic programme design, behaviour change, effective implementation and use of data.

This paper applies an implementation framework, based on a behavior change model, to compare four case studies of complementary feeding programs. It aims to expand our understanding of how to design and implement behavior change interventions aimed at improving complementary feeding practices. Four programs met the selection criteria of scale and documented improvements: Bangladesh, Malawi, Peru, and Zambia. We examined commonalities and differences in the design and implementation of social and behavior change approaches, use of program delivery platforms, challenges encountered, and lessons learned. We conclude that complementary feeding practices, in particular dietary diversity, can be improved rapidly in a variety of settings using available program platforms if interventions focus on specific constraints to food access and use effective strategies to encourage caregivers to prepare and feed appropriate foods. A five-step process is presented that can be applied across a range of complementary feeding programs to strengthen their impacts.

Improving maternal nutrition practices during pregnancy is essential to save lives and improve health outcomes for both mothers and babies. This paper examines the maternal, household, and health service factors influencing maternal nutrition practices in the context of a large scale maternal, newborn, and child health (MNCH) program in Bangladesh. Data were from a household survey of pregnant (n = 600) and recently delivered women (n = 2,000). Multivariate linear and logistic regression analyses were used to examine the determinants of three outcomes: consumption of iron and folic acid (IFA) tablets, calcium tablets, and diverse diets. Women consumed 94 ± 68 IFA and 82 ± 66 calcium tablets (out of 180 as recommended) during pregnancy, and only half of them consumed an adequately diverse diet. Good nutrition knowledge was the key maternal factor associated with higher consumption of IFA (β = 32.5, 95% CI: 19.5, 45.6) and calcium tablets (β ~31.9, 95% CI: 20.9, 43.0) and diverse diet (OR = 1.8, 95% CI: 1.0–3.1), compared to poor knowledge. Women’s self-efficacy in achieving the recommended practices and perception of enabling social norms were significantly associated with dietary diversity. At the household level, women who reported a high level of husband’s support were more likely to consume IFA (β = 25.0, 95% CI: 18.0, 32.1) and calcium (β = 26.6, 95% CI: 19.4, 33.7) tablets and diverse diet (OR = 1.9, 95% CI: 1.2, 3.3), compared to those who received low support. Health service factors associated with higher intakes of IFA and calcium tablets were early and more prenatal care visits and receipt of free supplements. Combined exposure to several of these factors was attributed to the consumption of an additional 46 IFA and 53 calcium tablets and 17% higher proportions of women consuming diverse diets. Our study shows that improving knowledge, self-efficacy and perceptions of social norms among pregnant women, and increasing husbands’ support, early registration in prenatal care, and provision of free supplements will largely improve maternal nutrition practices.

Background Use of three-dimensional (3D) color volume-rendered (VR) images has been reported to be more time-efficient compared to that of cross-sectional computed tomography (CT) images for the diagnosis of peroneal tendon dislocation. However, the diagnostic performance of this technique has not been studied. Purpose To test diagnostic accuracy of 3D color VR CT images of ankle for peroneal tendon dislocation in patients with acute calcaneal fractures. Material and Methods The study consisted of 121 ankle CT studies from 105 consecutive patients (85 men, 20 women; mean age, 42 years; age range, 16–75 years) with acute calcaneal fractures. Peroneal tendon dislocation was diagnosed on multiplanar CT images by consensus of two experienced musculoskeletal radiologists, which served as the reference standard. Three other musculoskeletal radiologists independently reviewed 3D images alone on a workstation. The readers determined whether or not there was peroneal tendon dislocation using three degrees of certainty (definite, probable, and possible). Diagnostic performance of 3D images for peroneal tendon dislocation was evaluated by calculating the sensitivities, specificities, and area under the receiver-operating characteristic (ROC) curves. Results Forty-eight (40%) out of 121 studies showed peroneal tendon dislocation based on the expert readings using multiplanar reformatted images. Sensitivities/specificities of 3D images measured 0.92/0.81, 0.88/0.90, and 0.81/0.92 for three readers, respectively. The area under the proper binormal ROC curve based on all three readers (0.93, 0.94, and 0.92) measured 0.93 with a 95% confidence interval of 0.89–0.98. Conclusion Diagnostic accuracy of 3D images is comparable to, but not as good as that of MPR images for the diagnosis of peroneal tendon dislocation in patients with acute calcaneal fractures.

Background Systems strengthening is essential for implementation of large-scale nutrition interventions, including infant and young child feeding (IYCF), since rapid geographic expansion places additional burdens on service delivery systems. Objective To document approaches for building capacity and supporting programs to scale up IYCF counseling in three different country contexts. Methods Situational assessments, stakeholder consultations, formative research, household and frontline health worker surveys, other related studies, and program monitoring in three countries identified gaps and opportunities for strengthening IYCF service delivery. Results Variations in program platforms, level and roles of service providers, places of service delivery, community factors, and the needs of managers and frontline workers influenced the intervention mix used for strengthening IYCF services. The programs ranged from a highly structured and standardized package of IYCF counseling services in Vietnam delivered through government health facilities to counseling delivered at the doorstep by incentivized nongovernmental organization volunteers in Bangladesh. In Ethiopia, government health extension workers based at health posts conducted outreach visits with support from volunteers. Conclusions Guidelines and standards of care, training, job aids, supportive supervision, incentives, and monitoring data can enhance performance and strengthen systems for delivering IYCF counseling services in the community or at health facilities. Leadership, financing, partnerships, and logistics support are essential to support large-scale implementation of the IYCF counseling package in diverse service delivery environments.

AliveThrive aims to increase exclusive breastfeeding and complementary feeding practices in Bangladesh, Ethiopia, and Vietnam.To develop and execute comprehensive communication strategies adapted to each context.We documented how three countries followed an established iterative planning process, with research steps followed by key decisions, to develop a communication strategy in each country. Secondary analysis and formative research identified the priority practices to focus on, and locally specific constraints to proper infant and young child feeding (IYCF). Communication strategies were then developed based on the social, cultural, economic, epidemiological, media use, and programmatic contexts of each country.There were widespread gaps between recommended and actual feeding practices, and these varied by country. Gaps were identified in household, community, and institutional levels of awareness and skills. Strategies were designed that would enable mothers in each specific setting to adopt practices. To improve priority behaviors, messaging and media strategies addressed the most salient behavioral determinants through face-to-face communication, social mobilization, and mass media. Trials of improved practices (TIPs), concept testing, and pretesting of materials proved useful to verify the relevance and likely effectiveness of communication messages and materials tailored for different audiences in each setting. Coordination and collaboration with multiple stakeholders from the start was important to harmonize messages and approaches, expand geographic coverage to national scale, and sustain the interventions.Our experience with designing large-scale communication strategies for behavior change confirms that systematic analysis and local planning cannot be omitted from the critical process of strategic design tailored to each context. Multiple communication channels matched to media habits in each setting can reach a substantial proportion of mothers and others who influence their IYCF practices. Preliminary data suggest that exposure to mass media plays a critical role in rapidly reaching mothers, household members, community influentials, and health workers on a large scale. Combining face-to-face interventions for mothers with social mobilization and mass media was effective in improving IYCF practices.

Despite the existence of a strong evidence base for investing in infant and young child feeding (IYCF), sufficiently supported IYCF policies and programs are rare.To develop evidence-based advocacy strategies in Bangladesh, Ethiopia, and Vietnam to enable policy change and to increase investments in and ensure scale-up and sustainability of IYCF programs.Situational analysis, formative and opinion leader research, and stakeholder consultations were used to develop three contextualized advocacy strategies.Data were used to determine how IYCF was perceived and prioritized, identify opinion leaders and partners, identify barriers to and opportunities for strengthening commitment, and select messages, materials, and communication channels. Opinion leader research showed that malnutrition was a concern but not a priority for policy action. Where food security was an issue, poverty reduction strategies rather than IYCF programs were viewed as the solution. Few opinion leaders were aware of the importance of the first 1000 days of life. In addition to policy gaps, awareness and implementation of existing policies were limited. This was often complicated by intragovernment conflicts and perspectives. Advocacy messages needed to be evidence based and delivered by credible champions. Engaging medical associations and the media presented an opportunity rarely leveraged in IYCF advocacy. CONCLUSIONS. Although sociopolitical contexts may vary, awareness of the importance of IYCF is an overarching advocacy challenge. Consequently, investments in IYCF programs and policies lag. Evidence-based advocacy design has a potential for impact on national policies, investments, and commitment to implementation and should be used more widely to inform program design.

Enteric diseases are often caused by poor hygiene and can contribute to stunting. From 50 randomly selected villages in Bangladesh, we collected quantitative and qualitative data on handwashing linked to child feeding to integrate handwashing promotion into a young child complementary feeding program. Most participants stated that the community knew the importance of handwashing with soap before food preparation and feeding a child, but had not developed the habit. We observed no handwashing with soap at these key times; sometimes hands were rinsed with water only. Most participants cited the unavailability of soap and water near the cooking place as a barrier to handwashing before food preparation. Most caregivers ranked nurturing messages as the best motivator to encourage handwashing with soap. An integrated intervention should include having soap and water available near the food preparation area and should use nurturing themes to encourage habitual handwashing with soap.

We assessed the effects of combining a mass media campaign with BCC by FHW on CF practices in Bangladesh. Survey data were collected from randomly sampled households with children 6–23 mo in 2010 (...

Background In Bangladesh, many programs and projects have been promoting breastfeeding since the late 1980 s. Breastfeeding practices, however, have not improved accordingly. Methods For identifying program-relevant issues to improve breastfeeding in infancy, quantitative data were collected through visits to households (n = 356) in rural Chittagong and urban slums in Dhaka, and qualitative data from sub-samples by applying semi-structured in-depth interviews (n = 42), focus group discussions (n = 28), and opportunistic observations (n = 21). Trials of Improved Practices (TIPs) (n = 26) were conducted in the above sites and rural Sylhet to determine how best to design further interventions. Our analysis focused on five breastfeeding practices recommended by the World Health Organization: putting baby to the breast within the first hour of birth, feeding colostrum and not giving fluids, food or other substances in the first days of life, breastfeeding on demand, not feeding anything by bottle, and exclusive breastfeeding for the first six months. Results The biggest gaps were found to be in putting baby to the breast within the first hour of birth (76% gap), feeding colostrum and not giving other fluids, foods or substances within the first three days (54% gap), and exclusive breastfeeding from birth through 180 days (90% gap). Lack of knowledge about dangers of delaying initiation beyond the first hour and giving other fluids, foods or substances, and the common perception of "insufficient milk" were main reasons given by mothers for these practices. Health workers had talked to only 8% of mothers about infant feeding during antenatal and immunization visits, and to 34% of mothers during sick child visits. The major providers of infant feeding information were grandmothers (28%). Conclusions The findings showed that huge gaps continue to exist in breastfeeding behaviors, mostly due to lack of awareness as to why the recommended breastfeeding practices are beneficial, the risks of not practicing them, as well as how to practice them. Health workers' interactions for promoting and supporting optimal breastfeeding are extremely low. Counseling techniques should be used to reinforce specific, priority messages by health facility staff and community-based workers at all contact points with mothers of young infants.

Background According to a World Health Organization (WHO) review of nationally representative surveys from 1993 to 2005, 42% of pregnant women have anemia worldwide. Almost 90% of anemic women reside in Africa or Asia. Most countries have policies and programs for prenatal iron–folic acid supplementation, but coverage remains low and little emphasis is placed on this intervention within efforts to strengthen antenatal care services. The evidence of the public health impact of iron–folic acid supplementation and documentation of the potential for scaling up have not been reviewed recently. Objective The purpose of this review is to examine the evidence regarding the impact on maternal mortality of iron–folic acid supplementation and the evidence for the effectiveness of this intervention in supplementation trials and large-scale programs. Methods The impact on mortality is reviewed from observational studies that were analyzed for the Global Burden of Disease Analysis in 2004. Reviews of iron–folic acid supplementation trials were analyzed by other researchers and are summarized. Data on anemia reduction from two large-scale national programs are presented, and factors responsible for high coverage with iron–folic acid supplementation are discussed. Results Iron-deficiency anemia underlies 115,000 maternal deaths per year. In Asia, anemia is the second highest cause of maternal mortality. Even mild and moderate anemia increase the risk of death in pregnant women. Iron–folic acid supplementation of pregnant women increases hemoglobin by 1.17 g/dL in developed countries and 1.13 g/dL in developing countries. The prevalence of maternal anemia can be reduced by one-third to one-half over a decade if action is taken to launch focused, large-scale programs that are based on lessons learned from countries with successful programs, such as Thailand and Nicaragua. Conclusions Iron–folic acid supplementation is an under-resourced, affordable intervention with substantial potential for contributing to Millennium Development Goal 5 (maternal mortality reduction) in countries where iron intakes among pregnant women are low and anemia prevalence is high. This can be achieved in the near term, as policies are already in place in most countries and iron–folic acid supplements are already in lists of essential drugs. What is needed is to systematically adopt lessons about how to strengthen demand and supply systems from successful programs.