Multisectoral community development in Nepal has greater effects on child growth and diet than nutrition education alone

Abstract

Objective: To compare the impact on child diet and growth of a multisectoral community intervention v. nutrition education and livestock management training alone.

Design: Longitudinal community-based randomized trial involving three groups of villages assigned to receive: (i) Full Package community development activities, delivered via women's groups; (ii) livestock training and nutrition education alone (Partial Package); or (iii) no intervention (Control). Household surveys, child growth monitoring, child and household diet quality measures (diet diversity (DD), animal-source food (ASF) consumption) were collected at five visits over 36 months. Mixed-effect linear regression and Poisson models used survey round, treatment group and group-by-round interaction to predict outcomes of interest, adjusted for household- and child-specific characteristics.

Setting: Banke, Nepal.

Participants: Households (n 974) with children aged 1-60 months (n 1333).

Results: Children in Full Package households had better endline anthropometry (weight-for-age, weight-for-height, mid-upper-arm-circumference Z-scores), DD, and more consumption of ASF, after adjusting for household- and child-specific characteristics. By endline, compared with Partial Package or Control groups, Full Package households demonstrated preferential child feeding practices and had significantly more improvement in household wealth and hygiene habits.

Conclusions: In this longitudinal study, a comprehensive multisectoral intervention was more successful in improving key growth indicators as well as diet quality in young children. Provision of training in livestock management and nutrition education alone had limited effect on these outcomes. Although more time-consuming and costly to administer, incorporating nutrition training with community social capital development was associated with better child growth and nutrition outcomes than isolated training programmes alone.

Trial registration: ClinicalTrials.gov NCT03516396.

Keywords: Animal-source foods; Child diet; Child growth; Multisectoral community intervention; Nepal; Nutrition education; Women’s groups.

Fig. 1

Schema showing the different activities in the three different groups: Full Package, Partial Package and Control, as well as the timing of data collection in the communities. Households with children aged 1–60 months from Banke, western Nepal, were randomized to receive: (i) multisectoral community development activities (Full Package), (ii) nutrition education and livestock management training alone (Partial Package) or (iii) no intervention (Control). The study was conducted between August 2013 and August 2017

Fig. 2

Number of households (HH), individuals and children aged <60 months included in the five surveys. HH with children aged 1–60 months from Banke, western Nepal, were randomized to receive: (i) multisectoral community development activities (Full Package), (ii) nutrition education and livestock management training alone (Partial Package) or (iii) no intervention (Control); the study was conducted between August 2013 and August 2017

Fig. 3

(a) Change in child growth indicators from baseline to endline in the Control (), Full Package () and Partial Package () groups. Mean WAZ, WHZ, HCZ and MUACZ increased significantly more in the Full Package group than in the other two groups; HAZ improved in the Partial Package and Control groups, but not in the Full Package group. Across-group comparison by anthropometric outcome: **P < 0·01, †P < 0·0001. (b) Adjusted marginal predictions from linear mixed-effects regression models, with their standard errors represented by vertical bars, showing significant improvements over time in the Full Package group with regard to MUAC, WHZ and WAZ (, Control; , Full Package; , Partial Package). Households with children aged 1–60 months from Banke, western Nepal, were randomized to receive: (i) multisectoral community development activities (Full Package), (ii) nutrition education and livestock management training alone (Partial Package) or (iii) no intervention (Control); the study was conducted between August 2013 and August 2017 (HAZ, height-for-age Z-score; WAZ, weight-for-age Z-score; WHZ, weight-for-height Z-score; HCZ, head circumference Z-score; MUACZ, mid-upper arm circumference Z-score; R1, Round 1 survey (baseline); R2–R5, Round 2 to Round 5 surveys)

Fig. 4

(a) Dietary diversity scores (DDS) for children did not differ at baseline among the three groups (, Control; , Full Package; , Partial Package). At R2 and R3, the DDS was significantly greater in the Control children than in the other two groups. However, this pattern then changed, and by R4 and R5, the Full Package children were consuming a significantly more diverse diet than the remainder of children (mean (sd): 5·38 (0·08) Full Package, 4·90 (0·06) Partial Package and 4·74 (0·07) Control at R4, P < 0·0001; 5·34 (0·08) Full Package, 4·84 (0·06) Partial Package and 4·91 (0·06) Control at R5, P < 0·0001). Across-group comparison: †P < 0·0001. (b) Adjusted marginal predictions from Poisson mixed-effects regression models, with 95 % confidence intervals represented by vertical bars, showing significant improvements over time in the Full Package group for child dietary diversity (, Control; , Full Package; , Partial Package). Households with children aged 1–60 months from Banke, western Nepal, were randomized to receive: (i) multisectoral community development activities (Full Package), (ii) nutrition education and livestock management training alone (Partial Package) or (iii) no intervention (Control); the study was conducted between August 2013 and August 2017 (R1, Round 1 survey (baseline); R2–R5, Round 2 to Round 5 surveys)

Fig. 5

(a) Animal-source food (ASF) consumption by children did not differ significantly at baseline between the three groups (, Control; , Full Package; , Partial Package). After an initial increase in ASF consumption noted in the Control group at R2 and R3, this declined, and by R4 and R5, the children in the Full Package consumed significantly more ASF than Partial Package and Control children (mean (sd): 1·00 (0·07) Full Package v. 0·78 (0·05) Partial Package and 0·69 (0·06) Control at R4, P = 0·0003; 1·29 (0·08) Full Package v. 0·81 (0·06) Partial Package and 0·96 (0·06) Control at R5, P < 0·0001). Across-group comparison: ***P < 0·001, †P < 0·0001. (b) Adjusted marginal predictions from Poisson mixed-effects regression models, with 95 % confidence intervals represented by vertical bars, showing significant improvements over time in the Full Package group for child ASF consumption diversity (, Control; , Full Package; , Partial Package). Households with children aged 1–60 months from Banke, western Nepal, were randomized to receive: (i) multisectoral community development activities (Full Package), (ii) nutrition education and livestock management training alone (Partial Package) or (iii) no intervention (Control); the study was conducted between August 2013 and August 2017 (R1, Round 1 survey (baseline); R2–R5, Round 2 to Round 5 surveys)

Fig. 6

(a) The share of children with the same or better dietary diversity score (DDS) compared with household-level DDS was significantly greater in the Control group at baseline (78 % Full Package, 75 % Partial Package v. 85 % Control, P = 0·0003; , Control; , Full Package; , Partial Package). However, by simple comparison, over the 36 months of surveys, there was a steady increase in the percentage of children in the Full Package and Partial Package groups whose DDS was the same as or better than the household DDS (R2 P = 0·03, R3 P = 0·05, R4 P = 0·01, R5 P = 0·0001). (b) Regarding difference in animal-source foods (ASF) consumed by the child and any other household member from baseline to endline, children in the Full Package and Partial Package significantly increased their consumption of ASF relative to what was available in the household. Across-group comparison: **P < 0·01. Households with children aged 1–60 months from Banke, western Nepal, were randomized to receive: (i) multisectoral community development activities (Full Package), (ii) nutrition education and livestock management training alone (Partial Package) or (iii) no intervention (Control); the study was conducted between August 2013 and August 2017 (R1, Round 1 survey (baseline); R2–R5, Round 2 to Round 5 surveys)

Fig. 7

From baseline to endline, household wealth score, hygiene practices (number of uses of soap cited) and dietary diversity score (DDS, number of food groups consumed) all improved significantly more in the Full Package group compared with the other two groups (respectively, P < 0·0001, P < 0·001 and P < 0·0001; , Control; , Full Package; , Partial Package). Across-group comparison: ***P < 0·001, †P < 0·0001. Households with children aged 1–60 months from Banke, western Nepal, were randomized to receive: (i) multisectoral community development activities (Full Package), (ii) nutrition education and livestock management training alone (Partial Package) or (iii) no intervention (Control); the study was conducted between August 2013 and August 2017