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

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 <6 months were excluded because they would not have been exposed to the SQ‐LNS component of the programme. Children up to 18 months were included because it was hypothesized that the programme's nutritional impact would be retained for several months after the programme ended, and there were substantial cost implications of including only children 6–12 months, as sampling would have required visiting a greater proportion of households in both health zones. Sample sizes (650 children per health zone per survey) were determined for the primary outcomes of the evaluation (to provide 80% power to detect a relative decline in the prevalence of anaemia of 15%). A total of 660 households were targeted in each health zone during both the baseline and endline surveys. In both surveys, trained interviewers asked caregivers about household sociodemographic characteristics and knowledge, attitudes, and behaviours relating to nutrition, IYCF, and SQ‐LNS. (Across both surveys >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.