An integrated infant and young child feeding and small-quantity lipid-based nutrient supplementation programme in the Democratic Republic of Congo is associated with improvements in breastfeeding and handwashing behaviours but not dietary diversity

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Study Justification:
– Integrating small-quantity lipid-based nutrient supplements (SQ-LNS) into infant and young child feeding (IYCF) programs can improve nutrient consumption in vulnerable populations.
– However, the impact of integrated IYCF-SQ-LNS programs on IYCF practices has not been extensively studied.
– This study aimed to assess the impact of an enhanced IYCF intervention, including SQ-LNS distribution and counseling, on IYCF practices in the Democratic Republic of Congo (DRC).
Highlights:
– The enhanced IYCF intervention in the DRC led to significant improvements in several important IYCF practices.
– Mothers in the intervention zone showed greater increases in initiating breastfeeding within 1 hour of birth, waiting until 6 months to introduce water and complementary foods, feeding the minimum meal frequency, feeding the child in a separate bowl, awareness of anemia, owning soap, and handwashing practices.
– However, the intervention did not result in a change in dietary diversity, with minimum dietary diversity and minimum acceptable diet remaining below 10% in both zones.
Recommendations:
– Future research should further investigate the potential of integrated IYCF-SQ-LNS programs to improve IYCF practices and children’s nutritional status.
– The provision of fortified complementary foods, such as SQ-LNS, can be an important source of essential nutrients for young children in areas with limited access to diverse foods.
Key Role Players:
– Health workers: Trained health workers played a crucial role in implementing the enhanced IYCF program and providing counseling to mothers.
– Community health workers (CHWs): CHWs supported the program by providing vaccination, vitamin A supplementation, and growth monitoring programs. They also played a role in IYCF counseling.
– District officials: District officials provided support and oversight for the program implementation.
Cost Items for Planning Recommendations:
– Training and informational materials development: Costs associated with developing training materials and informational resources for health workers and CHWs.
– Program implementation: Costs related to the distribution of SQ-LNS, counseling sessions, and monitoring and evaluation activities.
– Transportation: Budget items for providing transportation support, such as bikes for CHWs to reach remote areas.
– Communication: Costs associated with radio messages and other communication strategies to disseminate information about IYCF practices and the program.
Please note that the provided cost items are general categories and not actual cost estimates.

The strength of evidence for this abstract is 7 out of 10.
The evidence in the abstract is moderately strong, but there are some areas for improvement. The study design is a cross-sectional preintervention and postintervention survey, which provides some evidence of the impact of the enhanced IYCF intervention. The study includes a control group and uses difference in differences (DiD) analyses to compare the changes in key indicators between the intervention and control areas. The sample size is adequate, and the study adjusts for potential confounding factors in the multivariable models. However, the abstract does not provide information on the representativeness of the sample or the response rate, which could affect the generalizability of the findings. Additionally, the abstract does not mention any limitations of the study, such as potential biases or sources of error. To improve the evidence, future studies could consider using a randomized controlled trial design, providing more details on the sample characteristics and response rate, and discussing potential limitations.

Integrating small-quantity lipid-based nutrient supplements (SQ-LNS) into infant and young child feeding (IYCF) programmes can increase consumption of essential nutrients among children in vulnerable populations; however, few studies have assessed the impact of integrated IYCF–SQ-LNS programmes on IYCF practices. A 2-year, enhanced IYCF intervention targeting pregnant women and infants (0–12 months) was implemented in a health zone in the Democratic Republic of Congo (DRC). The enhanced IYCF intervention included community- and facility-based counselling for mothers on handwashing, SQ-LNS, and IYCF practices, plus monthly SQ-LNS distributions for children 6–12 months; a control zone received the national IYCF programme (facility-based IYCF counselling with no SQ-LNS distributions). Cross-sectional preintervention and postintervention surveys (n = 650 and 638 in intervention and control areas at baseline; n = 654 and 653 in each area at endline, respectively) were conducted in mothers of children 6–18 months representative of both zones. Difference in differences (DiD) analyses used mixed linear regression models. There were significantly greater increases in the proportion of mothers in the intervention (vs. control) zone who reported: initiating breastfeeding within 1 hr of birth (Adj. DiD [95% CI]: +56.4% [49.3, 63.4], P < 0.001), waiting until 6 months to introduce water (+66.9% [60.6, 73.2], P < 0.001) and complementary foods (+56.4% [49.3, 63.4], P < 0.001), feeding the minimum meal frequency the previous day (+9.2% [2.7, 15.7], P = 0.005); feeding the child in a separate bowl (+9.7% [2.2, 17.2], P = 0.01); awareness of anaemia (+16.9% [10.4, 23.3], P < 0.001); owning soap (+14.9% [8.3, 21.5], P < 0.001); and washing hands after defecating and before cooking and feeding the child the previous day (+10.5% [5.8, 15.2], +12.5% [9.3, 15.6] and +15.0% [11.2, 18.8], respectively, P < 0.001 for all). The enhanced IYCF intervention in the DRC was associated with an improvement in several important IYCF practices but was not associated with a change in dietary diversity (minimum dietary diversity and minimum acceptable diet remained below 10% in both zones without significant differences between zones). The provision of fortified complementary foods, such as SQ-LNS, may be an important source of micronutrients and macronutrients for young children in areas with high rates of poverty and limited access to diverse foods. Future research should verify the potential of integrated IYCF–SQ-LNS to improve IYCF practices, and ultimately children's nutritional status.

The enhanced IYCF programme was piloted in Haut‐Katanga District in Katanga Province; two health zones were selected, one as an intervention area (Kasenga) and one as a control area (Kipushi). Cross‐sectional baseline and endline surveys were conducted in both areas. The zones were selected for programmatic purposes with the intention of implementing the programme in the control area if the evaluation demonstrated an impact on childhood stunting and anaemia. The two zones were selected on the basis of the following specific criteria: (a) health areas in Haut‐Katanga District with large populations, (b) nonadjacency to Lubumbashi (the provincial capital), and (c) nonadjacency to each other. Distance from Lubumbashi was prioritized given the potential popularity of free SQ‐LNS distributions and the programmatic costs of distributions to children who resided outside of the intervention zone. Similarly, geographic distance between the intervention area and control area was essential to prevent spillover. Kasenga and Kipushi were the only two zones that fulfilled the selection criteria; however, there were some key differences in the areas. Kasenga (the intervention area) is a rural, ethnically homogenous (Bemba) area with an agricultural economy, whereas Kipushi (the control area) is a mining area that is home to several different ethnic groups. The control area received the government IYCF strategy based on the Essential Nutrition Actions (World Health Organization, 2013), whereas the intervention area received the enhanced IYCF intervention (Table 1). Site visits and key informant interviews in both areas prior to developing the intervention protocol revealed that in both areas, counselling on IYCF was provided in some health facilities, but that the coverage and training of health workers varied substantially across facilities and the use of job aids was rare. Community health workers (CHWs) were present in both the intervention and control areas (primarily to support vaccination, vitamin A supplementation, and growth monitoring programmes); however, they generally did not provide IYCF counselling. Details of the IYCF programme in Kipushi and Kasenga, Democratic Republic of Congo Note. ANC: antenatal care; CHW: community health worker; IYCF: infant and young child feeding; SQ‐LNS: small‐quantity lipid‐based nutrient supplements; UNICEF: United Nations International Children's Emergency Fund. The 2‐year enhanced IYCF programme targeted all 23,000 pregnant women and infants 0–12 months in Kasenga, using an expanded and locally adapted version of the UNICEF community‐based IYCF programme tools. The enhanced IYCF programme also included monthly distributions of SQ‐LNS for children 6–12 months and counselling for their mothers on the appropriate use of SQ‐LNS. All training and informational materials were developed on the basis of extensive formative research on the knowledge, attitudes, practices, and barriers to optimal IYCF practices. The formative research included focus groups and key informant interviews with mothers, fathers, health workers, and district officials as well as market visits to identify which nutrient‐rich foods were available during different times of the year (Tripp et al., 2015). In the intervention area, 30 health workers and 286 CHWs were trained to participate in the enhanced IYCF programme. In addition to receiving IYCF–SQ‐LNS training and counselling tools, CHWs in the intervention area were also given bikes to improve their ability to travel to remote areas and reinforce their community presence. In the intervention area, mothers of children aged 6–12 months were expected to receive monthly distributions of SQ‐LNS from health facilities as well as community‐ and facility‐based counselling on its appropriate use. SQ‐LNS was locally branded as “Kulabora,” which translates to “eating better.” Monthly distributions composed of four strips of seven sachets (totalling 28); each of the seven sachets contained images and text supporting one of seven key messages on Kulabora use, which also re‐enforced key IYCF and handwashing messages: (a) one packet per child per day, (b) wash your child's hands with soap and water before feeding, (c) breastfeed your child before giving food, (d) put a small amount of food that you think your child will eat in a separate bowl, (e) mix the Kulabora into the food, (f) feed the food mixed with the Kulabora to your child, and (g) Kulabora is for children from 6 to 12 months of age. The baseline survey was conducted in both health zones in October 2011; the endline survey was conducted in October–November 2014. The enhanced IYCF programme was initiated in the intervention area in September 2012, with the first SQ‐LNS distributions occurring in May 2013. Both surveys employed a two‐stage cluster sampling design. Using the UNICEF Multiple Indicator Cluster Survey sampling frame, 30 clusters were selected from each health zone using probability proportional to population size. There were 72 villages with approximately 6,655 children between 6 and 17.9 months of age in Kipushi and 219 villages and approximately 4,992 children in Kasenga. Before population size sampling, large clusters were split into approximately equal segments, and small clusters were combined with nearby villages. A list of all children 6–17.9 months in each selected cluster was then developed, and 22 children from each cluster were randomly selected; there were no replacements for households who refused to participate. The intervention targeted pregnant women and infants 0–12 months; however, the surveys included children 6–18 months. Children 97% of caregivers were biological mothers and are thus referred to as mothers from here on). Mothers were asked if they had heard of anaemia and if so to list the causes. They were also asked to recall breastfeeding practices in early life such as whether the child had ever been breastfed, how many hours or days after birth the mother initiated breastfeeding, when the mother introduced water for the first time, and when she introduced solid and semi‐solid foods. Interviewers also asked mothers to recall all of the foods and drinks the child consumed in the previous day. Interviewers were instructed to count the number of separate meals or snacks provided to the child (to calculate meal frequency) and also to use a list of 17 food groups and mark yes or no for each food group depending on whether the food was consumed in the previous day. Because mothers did not receive SQ‐LNS before the baseline survey, dietary recalls excluded SQ‐LNS (for comparability). In the endline survey, mothers were specifically asked about SQ‐LNS receipt and children’s consumption of SQ‐LNS. In the data analyses phase, the 17 food groups were collapsed to the standard seven food groups recommended in the WHO/UNICEF IYCF indicators (WHO/UNICEF/IFPRI/UCDavis/FANTA/AED/USAID, 2008). In accordance with the WHO/UNICEF indicators, minimum dietary diversity was defined as greater than or equal to four food groups (out of seven) in the previous day, minimum meal frequency as greater than or equal to two times per day for breastfed infants aged 6–8 months, greater than or equal to three times for breastfed children aged 9–23 months, and greater than or equal to four times for nonbreastfed children 6–23 months. For breastfed children, minimum acceptable diet was defined as minimum meal frequency and minimum dietary diversity. For nonbreastfed infants, minimum acceptable diet was defined as at least two milk feeds, minimum meal frequency and at least four out of six food groups (excluding the dairy food group) in the previous day. For handwashing indicators, interviewers observed whether the household had soap and then asked the mother whether she used soap the previous day and if yes, to list the purposes for which she had used soap. In the endline survey only, mothers were asked about exposure to specific components of the enhanced IYCF programme such as the following: whether she received information about breastfeeding during her last pregnancy, whether she received information about complementary feeding or handwashing at any point, and follow‐up questions on the content and source of that information. Mothers were also asked about SQ‐LNS knowledge, attitudes, and practices, as well as general indicators of programme exposure such as whether she participated in a group session on infant feeding at her last visit to the health centre for her child, whether she knows her CHW, and whether she had heard the radio messages on IYCF. We compared change in prevalence of key IYCF indicators from baseline to endline in the two health zones using difference in differences (DiD) analyses. Unadjusted and multivariable DiD (95% CI) estimates were obtained from mixed linear regression models with an interaction term between variables for health area (intervention vs. control) and time (endline vs. baseline), and cluster as a random effect (Card & Krueger, 1993). Based on a review of the literature, we determined a priori that multivariable models would adjust for child’s sex and age; maternal age, education (completion of secondary school and completion of primary school vs. less than a primary education), and ethnicity (Bemba vs. other ethnicity); and household’s primary source of income (agriculture, wage labour or daily work, or other), whether there was another child under 5 years of age in the household, and asset tertile. Asset tertile was derived from a principal component analysis of all households in the baseline and endline survey’s binary yes–no responses to ownership of a radio, television, mobile phone, refrigerator, stove, chair, bed, lamp, oven, hoe, sewing machine, bicycle, car, truck, and electricity (Vyas & Kumaranayake, 2006). Analyses were first conducted stratified by child’s age (among children ≤12 months and children >12 months); however, when no notable differences were found in the two age groups, they were collapsed. Prevalence ratios comparing programme exposure at endline in the intervention and control areas were obtained from linear mixed models with a log link, binomial distribution, and cluster as a random effect (Spiegelman & Hertzmark, 2005). Within the intervention area at endline, we also compared prevalence ratios for IYCF knowledge and practices among mothers with high versus low programme exposure (defined as 2–3 vs. 0–1 of the three exposures assessed in the endline survey: attendance at a health centre group IYCF session; receipt of IYCF, SQ‐LNS, or handwashing information from a CHW; and feeding the child SQ‐LNS). The initial analysis plan was to compare mothers with any exposure to the enhanced IYCF programme (1–3 of the exposures above) to an “unexposed group”; however, only 53 mothers in the intervention area at endline answered no to all three exposures. We thus collapsed mothers with 0–1 exposures into a single reference group defined as the “low exposure” group, compared with the “high exposure” (2–3 exposures) group. When the log‐binomial models did not converge, a log‐Poisson link function, which provides a consistent but less efficient empirical estimate of the prevalence ratio (Zou, 2004), was used. The National Statistics Office in Lubumbashi in DRC and the U.S. Centers for Disease Control (CDC) approved the protocol for the impact evaluation; the CDC determined the evaluation as public health practice. Interviewers explained the survey protocol to mothers and also informed mothers of the option to refuse to participate in the survey or to stop participation at any point. Given low rates of literacy in the area, all mothers provided verbal, informed consent to participate in the baseline and endline surveys, and interviewers indicated on the questionnaire when informed consent had been obtained.

Based on the information provided, here are some potential innovations that can be used to improve access to maternal health:

1. Integrated Infant and Young Child Feeding (IYCF) Programs: Implementing comprehensive IYCF programs that provide counseling and support to pregnant women and mothers on breastfeeding, complementary feeding, and handwashing practices. This can help improve breastfeeding initiation, appropriate introduction of water and complementary foods, and overall IYCF practices.

2. Small-Quantity Lipid-Based Nutrient Supplementation (SQ-LNS): Integrating SQ-LNS into IYCF programs can increase the consumption of essential nutrients among children in vulnerable populations. Monthly distributions of SQ-LNS can be provided to children aged 6-12 months, along with counseling for mothers on the appropriate use of SQ-LNS. This can help address nutrient deficiencies in areas with limited access to diverse foods.

3. Community-Based Counseling: Training and engaging community health workers (CHWs) to provide IYCF counseling and support. CHWs can play a crucial role in reaching and educating mothers in remote areas where access to healthcare facilities is limited. Providing CHWs with necessary training, tools, and resources can help improve maternal health outcomes.

4. Improved Training and Support for Health Workers: Ensuring that health workers receive comprehensive training on IYCF practices and are equipped with job aids to support their counseling efforts. This can help standardize and improve the quality of IYCF counseling provided in health facilities.

5. Behavior Change Communication: Implementing targeted behavior change communication campaigns to raise awareness and promote positive maternal health practices. This can include radio messages, community events, and educational materials that emphasize the importance of breastfeeding, handwashing, and appropriate complementary feeding.

6. Access to Essential Resources: Improving access to essential resources such as soap and clean water, which are necessary for proper handwashing practices. This can be achieved through community-level interventions, partnerships with local organizations, and government support.

7. Monitoring and Evaluation: Establishing robust monitoring and evaluation systems to track the impact of interventions on maternal health outcomes. Regular surveys and data collection can help identify areas for improvement and inform future programmatic decisions.

It is important to note that the specific context and needs of each community should be considered when implementing these innovations.
AI Innovations Description
The recommendation to improve access to maternal health is to implement an integrated infant and young child feeding (IYCF) program that includes the distribution of small-quantity lipid-based nutrient supplements (SQ-LNS). This program should target pregnant women and infants (0-12 months) in vulnerable populations, particularly in areas with high rates of poverty and limited access to diverse foods.

The IYCF program should include community- and facility-based counseling for mothers on handwashing, SQ-LNS, and IYCF practices. Monthly distributions of SQ-LNS should be provided for children aged 6-12 months. The program should also focus on improving breastfeeding practices, such as initiating breastfeeding within 1 hour of birth and waiting until 6 months to introduce water and complementary foods.

To ensure the success of the program, it is important to train and involve health workers and community health workers (CHWs). They should be equipped with the necessary knowledge and tools to provide effective counseling and support to mothers. CHWs can play a crucial role in reaching remote areas and reinforcing IYCF practices.

Monitoring and evaluation of the program should be conducted through baseline and endline surveys. These surveys should assess key indicators such as breastfeeding practices, dietary diversity, handwashing behaviors, and knowledge of maternal and child health. The data collected can help identify areas of improvement and measure the impact of the program.

It is also important to conduct formative research to understand the local context, including the availability of nutrient-rich foods and barriers to optimal IYCF practices. This research can inform the development of training materials and counseling tools that are tailored to the specific needs of the target population.

Overall, implementing an integrated IYCF program with a focus on SQ-LNS distribution can improve access to maternal health by promoting healthy feeding practices, increasing nutrient intake among children, and raising awareness of important health behaviors such as handwashing.
AI Innovations Methodology
Based on the provided description, here are some potential recommendations for improving access to maternal health:

1. Strengthening IYCF counseling: Enhance the training and capacity of health workers and community health workers to provide comprehensive and accurate counseling on infant and young child feeding practices, including the importance of breastfeeding within the first hour of birth, exclusive breastfeeding for the first six months, and appropriate introduction of complementary foods.

2. Promoting handwashing practices: Implement targeted interventions to promote handwashing practices among mothers and caregivers, emphasizing the importance of hand hygiene before preparing and feeding the child. This can include community-based awareness campaigns, provision of soap, and education on proper handwashing techniques.

3. Increasing access to small-quantity lipid-based nutrient supplements (SQ-LNS): Expand the distribution of SQ-LNS to reach more children in vulnerable populations, particularly those living in areas with limited access to diverse foods. This can be done through health facilities, community-based distribution programs, and partnerships with local organizations.

4. Strengthening community engagement: Engage community leaders, local organizations, and community health workers in promoting maternal health and IYCF practices. This can involve community mobilization activities, support groups for mothers, and community-led initiatives to address barriers to accessing maternal health services.

To simulate the impact of these recommendations on improving access to maternal health, a methodology could include the following steps:

1. Baseline data collection: Conduct a survey or data collection to gather information on the current status of maternal health, including access to healthcare services, knowledge and practices related to maternal and child health, and barriers to accessing care.

2. Intervention implementation: Implement the recommended interventions in selected areas or communities. This can involve training health workers, community health workers, and volunteers, distributing resources such as SQ-LNS and soap, and conducting community awareness campaigns.

3. Monitoring and evaluation: Collect data on key indicators related to maternal health and the recommended interventions. This can include tracking changes in knowledge and practices related to IYCF, rates of breastfeeding initiation, handwashing practices, and access to maternal health services.

4. Data analysis: Analyze the collected data to assess the impact of the interventions on improving access to maternal health. This can involve comparing pre- and post-intervention data, conducting statistical analyses to determine significant changes, and calculating indicators such as prevalence ratios and differences in differences.

5. Reporting and dissemination: Summarize the findings of the impact evaluation and communicate the results to relevant stakeholders, including policymakers, healthcare providers, and community members. This can help inform future decision-making and program planning to further improve access to maternal health.

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