Improving nutritional status among urban poor children in sub-Saharan Africa: An evidence-informed Delphi-based consultation

In sub-Saharan Africa (SSA), rapid urbanisation coupled with the high prevalence of infant and young child (IYC) undernutrition in low-income settings means that interventions to support IYC nutrition are a priority. Little is known about how urbanisation influences IYC feeding (IYCF) practices, and evidence-based interventions to improve IYC health/nutrition in the urban poor are lacking. Therefore, this research aimed to (a) systematically review evidence on interventions for improving the nutritional status of IYC aged 6–23 months living in urban poor areas (PROSPERO CRD42018091265) and (b) engage stakeholders to identify the highest ranking evidence gaps for improving IYCF programmes/policies. First, a rapid systematic review was conducted. This focused on the literature published regarding nutrition-specific and nutrition-sensitive complementary feeding interventions in urban poor areas, specifically low-income informal settlements, in low- and middle-income countries (LMICs). Six intervention studies met the review inclusion criteria. Intervention adherence was generally high, and indicators of maternal knowledge and IYC nutritional intake typically increased because of the interventions, but the impact on anthropometric status was small. Second, stakeholders working across SSA were engaged via a Delphi-based approach to identify priority areas for future intervention. Stakeholders reported that a situational analysis was required to better understand IYCF in urban poor areas, particularly the causes of IYC undernutrition, and highlighted the need to involve local communities in defining how future work should proceed. Together, these findings indicate a need for more evidence regarding IYCF and the factors that drive it in urban poor areas across LMIC settings, but particularly in SSA. A rapid review approach, with a simplified systematic review process, was used to obtain context‐sensitive knowledge in a shortened timeframe (Grant & Booth, 2009; Khangura, Konnyu, Cushman, Grimshaw, & Moher, 2012). The rapid systematic review protocol was registered on PROSPERO (registration number: CRD42018091265). The search was originally conducted to review and synthesise evidence on nutrition‐sensitive and nutrition‐specific interventions to improve the nutritional status of IYC in urban low‐income informal settlements in SSA. After screening titles, abstracts and full texts for inclusion (completed in May 2018), this search yielded one eligible article. Following consultation with stakeholders (government, academic and NGO representatives) at a meeting held in Nairobi, Kenya, in June 2018, the protocol was modified by expanding the search to include all LMICs because of the lack of evidence in SSA. The revised protocol was updated and reregistered with PROSPERO (registration number as above) in June 2018. For this review, LMICs were defined using the World Bank Group (2019) classification scheme (based on gross national income per capita). The rapid review was designed to follow on from a scoping review from some of the authors that examined risk factors for malnutrition in slums and the impact of interventions on children’s health in LMICs (Goudet, Griffiths, Bogin, & Madise, 2017). Key differences between the current protocol and the previous scoping review were to (a) include nutrition‐sensitive as well as nutrition‐specific interventions; (b) focus on IYC aged 6–23 months as opposed to all children under 5 years; (c) focus on diet quality outcomes, in addition to anthropometric outcomes. The search dates were set to identify new studies published since the scoping review search was completed in December 2013 (Goudet et al., 2017). Inclusion criteria for studies were based on the Population, Intervention, Comparison(s) and Outcome (PICO) structure (Thomas, Kneale, McKenzie, Brennan, & Bhaumik, 2019): (a) IYC aged 6–23 months in urban low‐income informal settlements or slums in LMICs; (b) nutrition‐specific or nutrition‐sensitive interventions, according to the definitions outlined by Ruel et al. (2013); and (c) quantitative outcomes of nutritional status indicators (length‐for‐age [LAZ], weight‐for‐height [WHZ] and weight‐for‐age [WAZ] z‐scores), undernutrition (stunting, underweight, wasting and micronutrient deficiencies) and diet quality (i.e., infant and young child MDD score, MMF and MAD). Eligibility criteria for the year of publication were from January 2014 to July 2018 (date of the search completion). The search, and summary of included studies, was completed prior to the stakeholder consultation (Delphi process) to inform this aspect of the research. We included studies that specified the location as being a slum or low‐income informal settlement in accordance with the UN‐Habitat (2004) definition criteria, that is, lacking one or more of the following indicators: access to improved water and sanitation facilities, security of tenure, durability of housing and sufficient living area. When the location of a study was not clearly defined in a published paper, we consulted team members/collaborators who had local knowledge and/or original authors to help us to decide if a study met our requirements for inclusion as an urban low‐income informal settlement or slum. Four electronic databases were searched: Medline, Scopus, Web of Science and Embase. An example search strategy (Medline) and the list of LMICs included in the search are provided in Data S1. The reference lists of existing systematic and/or literature reviews were also screened to identify further studies for inclusion. Citation follow‐up and hand searches were used to identify studies up until January 2019, which yielded one additional study (Smuts et al., 2019). Duplicates were removed before screening. The title, abstract and—subsequently—full‐text articles were screened against the inclusion criteria (by EKR, OM, TAZ, JMNC and EK). The review team pretested the screening form with an initial pilot phase of 15 studies. This process improved clarity of the inclusion criteria and consistency among assessors. An independent reviewer (RP) checked a random 10% sample of the excluded records at the title and abstract stages. Full‐text screening of articles was conducted by a second reviewer (EKR or OM) for confirmation. Any disagreements on study inclusion were discussed to reach consensus. If this was not possible, a third reviewer was consulted (PLG), and if necessary, authors were also contacted for further information about the study design to assess whether inclusion criteria were met. A data extraction form was developed, piloted on two studies and then used to collate the data from all included studies. Information extracted from studies included title, author(s), year of publication, type of intervention (nutrition‐sensitive or nutrition‐specific), details of intervention (type of intervention/supplement, etc.), intervention duration, details of intervention compliance, outcome measures assessed (child nutritional status and nutritional quality of diet, anthropometrics), any other outcome measures related to nutritional status/diet quality/malnutrition (specifically, stunting, underweight, wasting and micronutrient deficiencies), detailed results (list all relevant outcome measures separately), study limitations, and lessons learned in delivering the intervention. Data were extracted by two independent reviewers (NP and OM) and checked by EKR. Two reviewers (MM and EH) independently assessed the quality of the included studies using a 14‐item rating tool developed by Kmet et al. (2004). Their ratings were compared, and they came to an agreed rating for each criterion. As gold‐standard Cochrane guidance advises against the use of a rating score (Higgins & Green, 2006), a modified assessment classification was used. Instead of rating each criterion as either 0, 1 or 2, a qualitative, colour‐coded assessment of low quality/red (high risk of bias), medium quality/yellow or high quality/green (low risk of bias) was used, as has been done successfully in previous research (e.g., Rousham et al., 2020). If all 14 criteria were rated as ‘high/green’ then a ‘high’ overall quality assessment was awarded. Papers that had a combination of green and yellow (high/medium quality) ratings received a ‘medium’ overall quality rating. A ‘low’ overall quality assessment was given if any of the 14 criteria were assessed as ‘low/red’. We built on our findings from the rapid review by conducting a stakeholder consultation to determine the priority areas for improving IYCF programmes and policies in SSA. We adopted a consensus‐gathering approach based on the Delphi method (Iqbal & Pipon‐Young, 2009) and consulted a range of stakeholders (‘panellists’) who contributed to three phases of information generation and consensus gathering. Consultation methods included two face‐to‐face stakeholder workshops (in Nairobi, Kenya, and Lilongwe, Malawi) and a survey that was distributed either online, as a paper‐based survey or via individual telephone interviews with stakeholders. This project came about through a nutrition network involving two Africa‐wide organisations (African Population and Health Research Centre [APHRC], Kenya, and African Institute for Development Policy [AFIDEP], Malawi) and so these locations in Kenya and Malawi were the starting point for the stakeholder engagement activities, which expanded from there outwards to bring in stakeholders working across SSA. Participants were individuals with experience of working or conducting research into IYC nutrition in SSA. Purposive sampling was used to identify potential participants. Participants were all aged 18 years or over. Prior to recruitment, ethical clearance was obtained from Loughborough University, from the Amref Health Africa Ethics and Scientific Review Committee (AMREF‐ESRC P528/2018) in Kenya and from the National Committee on Research in the Social Sciences and Humanities (No. P.12/18/336) in Malawi. Informed consent was given by all participants who took part in the workshops or completed the survey. A modified Delphi method was implemented, comprising three rounds. The Delphi method is interested in the formation or exploration of consensus, and it is exceedingly useful for topic areas where there is limited research because input and ideas come from a range of expert stakeholders (Iqbal & Pipon‐Young, 2009). Initially, evidence from the rapid review’s synthesis of the recent research evidence identified gaps in knowledge in relation to IYCF, particularly complementary feeding, in LMICs. The research team drew on their knowledge and experience to summarise the research gaps in relation to SSA. These evidence‐informed gaps formed the basis of the first round of the modified Delphi approach. Evidence gaps were shared with a range of stakeholders from Kenya and Malawi at a face‐to‐face meeting in Nairobi, Kenya, in June 2018 (n = 18). Stakeholders were identified by co‐investigators in each country based on a list of target sectors (e.g., Ministry of Health, NGOs including practitioners and implementers, policymakers, academics, county government health officials, research institutions, professional networks [e.g., the African Nutrition Society and UNICEF]) to ensure a breadth of views would be represented. These stakeholders were invited to contribute their views about whether these evidence gaps were deemed to be (the most) important, as well as to offer their perspective—and to generate ideas—on where more evidence is needed to improve the nutritional status of IYC living in urban low‐income informal settlements or slums in SSA. Stakeholders discussed the questions posed in small groups, facilitated by a discussion leader. Notetakers recorded stakeholders’ views and opinions. An example question asked of the stakeholders was What is the evidence needed to enable the formulation and implementation of policies and programmes to improve child nutritional status? The use of open‐ended questions, yielding qualitative data, is recommended for Round 1 because at this stage, the Delphi method focuses on the ‘future thinking’ on the issue (Iqbal & Pipon‐Young, 2009). Notes from the discussions were subsequently used to inform Round 2. Following the stakeholder meeting (Round 1), the information gained was used to create a survey, which was developed and refined by the multidisciplinary research team. An initial pool of survey items was developed, reviewed and refined by the research team. The final survey comprised 57 items, alongside some questions about participants’ background to give context on their level of experience. The survey items were divided into three sections: (A) Nutritional status of urban poor families (11 items); (B) What is already known? (18 items); and, (C) What future work is needed, and how can this be done? (28 items). At the start of each section, participants were reminded of the statements related to the nutritional status of urban poor families and programmes/interventions/policies that might exist to support IYC feeding or nutrition and to think about IYC under 2 years when responding. Participants were asked to indicate the extent to which they agreed/disagreed with each statement, using a 5‐point scale. The survey was either completed online or administered as a face‐to‐face interview with a wide range of stakeholders who worked across SSA to gain their input into the evidence gaps and where further work/research is required. The online survey was distributed via the African Nutrition Society and by sending emails directly to relevant stakeholders. The aim of this round was to determine whether there was broad consensus in respondents regarding the evidence gaps highlighted by the rapid review. The third and final round was conducted (a) at a second stakeholder meeting held in Malawi in January 2019 and (b) by emailing all of the other respondents (i.e., those not in attendance at the meeting) who had completed the Round 2 survey. Synthesised views from Round 2 were shared with stakeholders for any comments. Stakeholders were asked to select priority areas from the list of future directions. Six items related to what future work is needed, and how this can be done, when thinking about the causes of (mal)nutrition in urban poor IYC (focusing on undernutrition), and 22 items related to what future work is needed, and how this can be done, thinking about potential solutions to (mal)nutrition in urban poor IYC (Data S2). Respondents were asked to indicate their top two priorities from the list of six items and their top seven from the list of 22 items. Responses were collated and used to determine what stakeholders working in SSA believed were the most important priority areas for future work. Descriptive statistics were calculated. Round 1 information was collated, synthesised and used to inform the generation of Round 2 questions. Consensus in Round 2 was defined as ≥70% of participants either agreeing/strongly agreeing or disagreeing/strongly disagreeing with each statement. The level of agreement was set at ≥70%, as in previous studies (e.g., Diamond et al., 2014; Vogel et al., 2019). All ‘neutral’ responses were removed prior to calculating the percentage agreement/disagreement to ensure that only those who were confident with their answer were included (as per Vogel et al., 2019). For Round 3, priority areas for future work were identified, and responses were summed across participants to indicate the items with the greatest support.