The potential effectiveness of the nutrition improvement program on infant and young child feeding and nutritional status in the Northwest and Southwest regions of Cameroon, Central Africa

Background: Despite the recent international focus on maternal and child nutrition, little attention is paid to nutrition capacity development. Although infant feeding counselling by health workers increases caregivers’ knowledge, and improves breastfeeding, complementary feeding, and children’s linear growth, most of the counselling in sub-Saharan Africa is primarily conducted by nurses or volunteers, and little is done to develop capacity for nutrition at the professional, organizational, or systemic levels. The Cameroon Baptist Convention Health Services Nutrition Improvement Program (NIP) has integrated a cadre of nutrition counselors into prevention of mother-to-child transmission of HIV programs, infant welfare clinics, and antenatal clinics to improve infant and young child feeding practices (IYCF). The study objective was to evaluate the effects of NIP’s infant feeding counselors on exclusive breastfeeding (EBF), complementary feeding (CF), and children’s linear growth. Methods: A cross-sectional evaluation design was used. Using systematic random sampling, caregivers were recruited from NIP sites (n = 359) and non-NIP sites (n = 415) from Infant Welfare Clinics (IWCs) in the Northwest (NWR) and Southwest Regions (SWR) of Cameroon between October 2014 and April 2015. Differences in EBF and CF practices and children’s linear growth between NIP and non-NIP sites were determined using chi-square and multiple logistic regression. Results: After adjusting for differences in religion, occupation, and number of months planning to breastfeed, children were almost seven times (Odds Ratio [OR]: 6.9; 95% Confidence Interval [CI]: 2.30, 21.09; β = 1.94) more likely to be exclusively breastfed at NIP sites compared to non-NIP sites. After adjusting for differences in occupation, religion, number of months planning to breastfeed, rural environment, economic status, attending other Infant Welfare Clinics, and non-biological caregiver, children were five times (OR: 5.5; CI: 3.37, 9.02; β = 1.71) more likely to be stunted at non-NIP sites compared to non-NIP sites. Conclusion: Training a cadre of nutrition counselors is one approach towards increasing nutrition human resources to implement nutrition interventions to improve maternal and child nutrition. In this research project, the study design did not allow for conclusive results, but rather suggest IYCF counseling provided by nutrition counselors was effective in increasing EBF and reduced the risk of stunting in children 6-8 months. This was a comparative cross-sectional evaluation. The study population were caregivers, between the ages of 18–50, and their infants between the ages of 0 and 8 months. Caregivers were recruited from three existing Northwest Region CBCHS NIP sites (one urban hospital, one rural hospital, one rural health center) and one existing Southwest Region CBCHS NIP site (one urban hospital). Comparison group participants came from non-NIP sites (one urban hospital and one rural health center in the Northwest Region; one urban health center and one rural health center in the Southwest Region) and matched for demographics. Both regions, from which participants were recruited, are tropical in climate with year-round access to food and the majority of residents rely on subsistence farming and attain at least a primary-level education. According to the WHO Global Databank on Infant and Young Child Feeding, the average percent of infants who were exclusively breastfed and complementary feeding practices in the NW and SW Regions was 34 and 78% respectively [21]. In the sample size calculations these statistics were used as a proxy measure of exclusive breastfeeding and complementary feeding practices at non-NIP sites. According to the NIP records for the month of January 2014, 78% of children were exclusively breastfed and 85% received complementary foods. Comparing the probabilities from NIP and non-NIP sites at a power of 90%, an alpha level of .05, 10% attrition, and an equal allocation ratio for a logistic regression test, a total sample size of 130 NIP and non-NIP caregivers with children between the ages of 0–5 months and 630 NIP and non-NIP caregivers with children between the ages of 6–8 months was needed. The statistical software program G*Power was used to determine sample size [22]. Caregivers who presented at the IWC clinics during the data collection periods were recruited through systematic random sampling using a sampling interval, which was calculated based on the average daily attendance at IWCs. Every person recruited was given the opportunity to participate or not participate in the evaluation and assured of the same quality of health care. At NIP sites there were 354 caregivers and at non-NIP there were 415 caregivers who completed the questionnaire October 2014-April 2015. Figure 1 demonstrates how data was collected from NIP and non-NIP sites for caregivers with children between 0–5 and 6–8 months. Data Collection An adapted validated IYCF questionnaire was used to determine exclusive practices breastfeeding, timing of introduction to complementary feeding [23], and demographic information (please see Additional file 1). The IYCF questions were modified to reflect common locally available foods (pap, fufu, njamajama) and collect relevant demographic data. The demographic variables such as caregiver’s religion (Muslim, Christian, or other), gender, years of education, occupation, number of children, marital status, region of residence (NW or SW), location of health center (rural or urban), number of months planning to breastfeed, attendance of IWC at other health centers, and economic status were gathered from the questionnaire. The ownership of a radio, television, motorbike, and car were summed to determine economic status. This method of measuring economic status was found effective in a Cameroonian study that sought to determine child nutritional status by household and community socioeconomic status [24]. Prior to data collection, the questionnaire was pre-tested on a small sample and further revised to suit the Cameroonian context. Data collectors were trained to verbally administer the questionnaires to eligible caregivers and collect their children’s anthropometric measurements at the Infant Welfare Clinics (IWCs) at four NIP sites and four non-NIP recruitment sites. To determine children’s nutritional status, anthropometric measurements (weight-for-height, height-for-age) were collected using standardized procedures to permit reproducibility and accuracy. When infants came to the IWC, they were weighed naked on a baby scale measured to the nearest 10 g. Recumbent length was measured to the nearest millimeter using horizontal measuring boards. All infant weight and height measurements were taken in duplicate by the data collectors and if there were any differences between measurements greater than 0.1 kg in weight and .1 cm in height, a third measurement was taken to ensure accuracy. The age of the child was determined using the child’s health record when available. When not available, the child’s age was obtained from the caregiver. The infant’s anthropometric measurements were recorded on the questionnaire. The WHO 2006 indices for weight-for-height and height-for-age were used for comparison. Exclusive breastfeeding under 6 months was defined as the proportion of infants 0–5 months of age who were fed exclusively with breastmilk the previous day. Complementary feeding was expressed as the introduction of solid, semi-solid or soft foods between 6 and 8 months. The 24-h recall method was used to measure the proportion of infants who were exclusively breastfed or received complementary foods in the past 24 h, per the World Health Organization’s standards [23]. If a child’s weight-for-height z-score was below 2 standard deviations, the child was considered wasted. If the child’s height-for-age z-score was below 2 standard deviations, the child was considered as stunted. The child’s anthropometric measurements were analyzed to determine if there was a difference in children’s nutritional status between those who did and did not receive NIP counseling. The WHO Anthro Software 3.2.2 was used to determine if a child was stunted or wasted based on their height for age and weight for height z-score. Chi-square was used to measure differences in demographics, exclusive breastfeeding, complementary feeding, stunting, and wasting between caregivers and their children who received services at NIP sites and those who received services at non-NIP sites. Binary logistic regression determined if caregivers at NIP sites were significantly more likely to exclusively breastfeed or provide timely complementary foods and if children at NIP sites were less likely to be stunted or wasted after adjusting for confounders. Caregivers with children 0–5 months were analyzed separately from caregivers with children 6–8 months. All data was analyzed using SPSS version 23 [25].