Community-based educational Intervention improved the diversity of complementary diets in Western Kenya. Community-based educational intervention improved the diversity of complementary diets in Western Kenya: results from a randomized control trial improving the diversity of complementary diets in Western Kenya. Presentation by Lydiah M. Waswa: PhD Student, Justus Liebig University- Giessen Find out more about this research: http://www.bioversityinternational.org/news/detail/improving-nutrition-through-local-agricultural-biodiversity-in-kenya/

1. Community-based educational intervention improved the
diversity of complementary diets in Western Kenya: results
from a randomized control trial
Lydiah M. Waswa: PhD Student , Justus Liebig University- Giessen
28th August 2014

2. Background
• Prevalence of malnutrition in Kenya:
 35% of children aged under five were stunted, 16%
underweight and 7% wasted
• Lack of diversity is a major problem among infants and young
children during the complementary feeding period
• Diets of children are staple-based including few or no animal
source foods, vegetables and fruits
Only 39% of children 6-23 months in Kenya are fed with diets reaching the
minimum required dietary diversity (4 out of 7 food groups) (KDHS, 2008/9)

3. Background…..
• Inappropriate feeding practices during the complementary feeding
period contribute to inadequate nutrient intake among infants and
young children
• Even when food resources are available in the home, caregivers are
not able to make the best use of them:
 Inadequate knowledge
 Cultural beliefs and practices
 Inappropriate advice
• Need for interventions to improve the quality of complementary
foods by promoting the consumption of a variety of foods,
including local foods

4. Objective
• The study aimed to assess the effect of an education intervention
focusing on the utilization of local agro-biodiversity in improving
the:
Diversity of complementary diets and
Nutrition knowledge of caregivers

5. Hypotheses
It was hypothesised that:
 Children whose caregivers participated in the nutrition education
intervention would receive more diversified complementary diets
Caregivers who participated in the nutrition education sessions
would have improved nutrition knowledge

6. Methods

7. Study Setting
Teso South
LM1, LM2
1550-1800 mm
Bondo
LM3, LM4,LM5
1020-1100 mm

8. Study Flow
Baseline survey in households with children 6-23 months and their caregivers
Middle survey in same households with children 6-23 months and their caregivers
to capture seasonal differences, Nov 2012 (n=218)
Intervention Group (10 villages) Control Group (10 villages)
8
Jul/Aug 2012 (n=293)
Restricted cluster randomization (using baseline results)
District, AEZs, wealth index, stunting, CDDS, education level of caregivers
Nutrition education sessions on
complementary feeding
Feb-Jun 2013
Endline survey in households children aged 6-23 months and their caregivers
Jul/Aug 2013 ; Intervention group (n=110),Control group (n=97)

9. Study Flow
Baseline survey in households with children 6-23 months and their caregivers
Middle survey in same households with children 6-23 months and their caregivers
to capture seasonal differences, Nov 2012 (n=218)
Intervention Group (10 villages) Control Group (10 villages)
9
Jul/Aug 2012 (n=293)
Restricted cluster randomization (using baseline results)
District, AEZs, wealth index, stunting, CDDS, education level of caregivers
Nutrition education sessions on
complementary feeding
Feb-Jun 2013
Endline survey in households children aged 6-23 months and their caregivers
Jul/Aug 2013 ; Intervention group (n=110),Control group (n=97)

10. Study population
• Baseline survey
• Households with caregivers and children 6-23 months
• Two stage cluster sampling
 15 villages randomly from each district proportional to population size
 10 households randomly selected per village
• Intervention
 10-15 caregivers with children 6-17 months in each intervention village
• Endline survey
• Intervention group: All caregivers who participated in the NE
• Control group: 10 households per village randomly selected
 207 caregivers interviewed: Control (n=97), Intervention (n=110)

11. Key Principles
• Community health workers (CHWs) received three days training
on the topics of the nutrition education sessions
• Nutrition education (NE) sessions conducted jointly with the
CHWs
• NE sessions were participatory:
• Group discussions
• Cooking demonstrations
 Caregivers brought ingredients/ foods
 Using cooking tools and fuels from participants

12. Nutrition education sessions
Sessions Time Topics Materials
1 February • The importance of complementary feeding
Main activity: participatory group discussions
IYCF materials
2 February-
March
• Dietary diversity during complementary
feeding
• Cooking demonstration
Main activities: participatory group discussions and
cooking demonstration
Food circle, Seasonal
food availability
calendars,
Locally available foods
General Elections in March 2013 and Follow-up visits in April 2013
3 May • Making nutritious and diverse meals for
children aged 6-23 months
• Cooking demonstration
Main activities: participatory group discussions and
cooking demonstration
IYCF materials, Food
circle, Seasonal food
availability calendars,
Locally available foods
4 June • How to obtain and prepare adequate and
nutritious meals for children 6-23 months
Main activities: group discussions and presentations
Posters, Brochures:
Food circle, Nutritious
snacks etc.
The themes and topics for the nutrition education sessions were selected based on the findings from the
baseline survey with reference to materials from FAO 2004 and UNICEF 2012

13. Data collection
• Semi-structured questionnaires
Socio-demographic data
Child feeding practices
Nutrition knowledge of caregivers
• 24 hour recalls to assess
nutrient intakes and dietary
diversity
• Anthropometric measurements:
 Women: weight, height
 Children: Length, weight
Bioversity International L. Waswa
Bioversity International L. Waswa

14. Data analysis
• Data was analysed using SPSS version 22
• Children’s dietary diversity scores (CDDS) calculated from the
24-hour recalls based on seven food groups (WHO 2010)
 Score range:0-7
• Infant and young child feeding practices assessed based on
WHO 2010 infant and young child feeding indicators:
 minimum dietary diversity (MDD)
 minimum meal frequency (MMF)
 minimum acceptable diet (MAD)

15. Data analysis….
• Wealth Index: Principal Component Analysis (PCA)
Characteristics of household dwelling
Household ownership of consumer durables
Land ownership
• Nutrition knowledge score was computed based on:
 Caregivers’ knowledge of vitamin A, iron and vitamin C
Food sources of the nutrients
Importance of feeding children foods rich in these nutrients
Score range: 0-21

16. Data analysis
• Descriptive analyses:
 Chi-square test for nominal variables
 T-test for continuous variables
 Mann-Whitney test for ordinal variables
• Treatment effect was assessed using the difference-in-differences (DiD)
estimator inside a generalized estimating equations (GEE) framework:
 To account for a data structure where 25% of the data are panel data and the remaining
75% are repeated cross sectional data
• CDDS and the knowledge score treated as count variables
 Count regression with Poisson link function and negative binominal function in the
statistical models
 Results from Poisson regression are presented as incidence rate ratio (IRR) which
expresses the treatment effect as a percentage
• Binary outcomes (MDD, MMF, MAD) were analysed using logistic regression
inside the GEE framework

17. Results

18. Selected household characteristics
Characteristics
Baseline (n=198) Endline (n=207)
Control
(n=99)
Intervention
(n=99)
Control
(n=97)
Intervention
(n=110)
Age children months (mean ±SD) 14 ±5.15 14 ±4.6 16 ±5.11 17 ±4.30
Age caregivers years (mean ±SD) 25 ±5.04 27 ±7.32 26 ±6.20 26 ±6.49
Household size (mean ±SD) 6 ±2.83 6 ±2.45 6 ±2.20 6 ±2.30
Education caregiver (%)
No education 9 3 4.1 3
Some primary educ. 41 46 34 50
Completed primary educ. 31 31 36 23
Some secondary 9 13 16 16
Completed secondary 7 5 6 6
Higher education 2 2 4 3

19. Infant and young child feeding practices
Variables
Baseline (n=198)
P
Endline (n=207)
P
Control
(n=99)
Intervention
(n=99)
Control
(n=97)
Intervention
(n=110)
n % n % n % n %
Minimum Dietary Diversity
(MDD)
50 51 55 56 ns 54 56 96 87 <0.001*
Minimum Meal Frequency
(MMF)
72 74 58 59 ns 70 75 81 77 ns
Minimum Acceptable Diet
(MAD)
42 43 45 46 ns 45 46 85 77 <0.001*
*Chi square test, ns=not significant
WHO (2010) Indicators for assessing infant and young child feeding practices: Part 2 Measurement.

20. Consumption of foods from different food
groups
0 10 20 30 40 50 60 70 80 90 100
Grains, roots and
tubers
Dairy products (milk)
Legumes, nuts and
Flesh foods (meat,
poultry, fish)
Other fruits and
vegetables
Vitamin A rich fruits
and vegetables
Eggs
seeds
Percentage (%)
Endline Intervention
Endline Control
Baseline Intervention
Baseline Control
*
*
*
*
*

21. Effect of intervention on CDDS
• Mean CDDS in the control and
intervention groups did not differ
significantly at baseline (P=0.510)
• At endline, mean CDDS was significantly
higher in the intervention group compared
to the control group, P <0.001
• Mean CDDS in the control group dropped
significantly at endline, P=0.006
The endline rate of CDDS was at
85.6 % of the baseline values
(incidence rate ration (IRR) = 0.856)
3.78 4.02
3.4
4.84
7
6
5
4
3
2
1
0
Control group Intervention group
Mean CDDS (0-7)
Baseline survey (n=198)
Endline survey (n=207)

22. Effect of intervention on CDDS
• The treatment effect on CDDS
was large, positive and significant
(P=0.001)
• The results showed an estimated
average treatment effect on the
CDDS of plus 27% (IRR=1.27)
CDDS rate of the children in the
intervention group was 27% larger than
it would have been without the
treatment
3.78 4.02
3.4
4.84
7
6
5
4
3
2
1
0
Control group Intervention group
Mean CDDS (0-7)
Baseline survey (n=198)
Endline survey (n=207)

23. Effect of intervention on infant and young child
feeding indicators
Indicator Odds Ratio
(OR)
95% CI P
Minimum dietary diversity
(MDD)
4.46 1.84-10.83 0.001
Minimum meal frequency
(MMF)
2.21 0.91-5.36 0.080
Minimum acceptable diet
(MAD)
3.41 1.50-7.76 0.004
Analysis using the DiD model with logistic regression for binary dependent variables

24. Effect of intervention on the nutrition knowledge
of caregivers
• Mean nutrition knowledge score in
the control and intervention groups
did not differ significantly at
baseline, ( P=0.176)
• At endline, mean nutrition
knowledge score was significantly
higher among caregivers in the
intervention group compared to
those in the control group, P<0.001
3.66
2.69 3.14
8.21
14
12
10
8
6
4
2
0
Control group Intervention group
Mean nutrition knowledge scores (0-21)
Baseline survey (n=198)
Endline survey (n=207)

25. Effect of intervention on nutrition knowledge of
caregivers
• The treatment had a large,
positive and significant effect on
the nutrition knowledge scores
of the caregivers (IRR=2.05),
P<0.001
• Nutrition knowledge score did
not have a significant or strong
effect on CDDS (P=0.731)
2.69
3.14
3.66
8.21
14
12
10
8
6
4
2
0
Control group Intervention group
Mean nutrition knowledge scores (0-21)
Baseline survey (n=198)
Endline survey (n=207)

26. Effect of intervention on CDDS and nutrition knowledge
of caregivers
Nutrition
education
intervention
Children’s
dietary
diversity
scores
P=0.731
Nutrition
knowledge
score of
caregivers
P<0.001
P<0.001
Significant effect
No significant effect

27. Conclusions and
recommendations

28. Conclusion
• The nutrition education intervention:
 Motivated the caregivers to use local food resources to
improve the diversity and quality of complementary diets
 Low consumption of animal source foods especially flesh meats and
eggs
 Enhanced nutrition knowledge of caregivers
 The increase in nutrition knowledge did not have a direct and significant
effect on the CDDS
 While increased nutrition knowledge is an important factor, on its own it
cannot lead to changes in behaviours

29. Recommendations
Nutrition education may be more effective when:
 Combined with other strategies that enhance accessibility to
affordable, culturally acceptable, nutrient dense foods
 Longer implementation period:
To enable assessment of the long term impact of such interventions on child feeding
practices and growth outcomes
Include other members of the family especially fathers and
grandmothers:
Have great influence on child feeding and caring practices
Provide a supportive environment that would enable lasting behaviour change among
caregivers

30. Acknowledgements
• Supervisors:
- Prof. Michael Krawinkel (JLU-Giessen)
- Dr. Gudrun Keding (Bioversity)
- Dr. Irmgard Jordan (JLU-Giessen)
• Funding sources:
– BMZ/ GIZ
– DAAD/ NCST
• Caregivers and their children
• Community health workers
• Local administration
• Enumerators and data entry
clerks
• INULA colleagues and
Bioversity staff

31. Thank you
www.bioversityinternational.org