Presented by Alexander Kalimbira Presented at 2015 ECAMA Research Symposium Malawi Institute of Management, 4-5 June

1. Impact of Food Security Interventions
& Nutrition Education on Child Dietary
Diversity
Results from 3 Cross-sectional Surveys
The IMCF Team
at the 2nd ECAMA Symposium
Malawi Institute of Management
Lilongwe
04 June 2015

2. Improving Infant & Young Child Feeding
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3. Background – as of 2011
 Inappropriate feeding practices during the complementary feeding
period contribute to inadequate nutrient intake among infants &
young children
 Even when food resources are available in the home, caregivers are
not able to make the best use of them:
 Inadequate knowledge
 Unhealthy beliefs & practices
 Inappropriate advice
 Need for interventions to improve quality of complementary foods by
promoting consumption of a variety of foods, including local foods
 Lack of evidence! 3

4. IFSN Project
To improve food security & nutrition:
• Support to joint nutrition education between Agriculture and Health
for increased impact of knowledge and skills on: production,
processing, storage and utilization including improved
complementary feeding practices
• Distribution of a range of agricultural inputs to vulnerable
households including those with young children and pregnant
women
• Increased diversification of local production to include different
livestock and nutritious food crops covering the six food groups

5. Key Activities
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 Promote diversified agriculture to improve availability,
access and utilization of all six food groups
 Capacity building of farmers, lead farmers, frontline staff
 Promote income generating activities: fruit trees, apiary,
mushrooms, vegetables, cassava, Irish potatoes, orange-
fleshed sweet potatoes
 Promotion of environment, soil & water conservation
 Improve water & sanitation
 Promotion of small scale irrigation-gravity fed, treadle
pumps, residual moisture

6. Objectives of the Research Project …
… was to test the following hypotheses:
1. TIPs formative research generates behaviour
change communication messages & nutritionally
improved recipes that lead to lasting improvements in
complementary feeding practices, dietary intakes &
child nutritional status
2. Locally available & affordable foods can provide a
significant contribution to the nutritional requirements of
children 6-23 months
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7. 3. Nutrition education with focus on IYCF & linked with
a food security intervention can improve child
feeding practices & nutritional status, &
4. Using locally available foods for improving
complementary feeding practices & children’s nutrition
status is a sustainable strategy, which can be
replicated by households at low cost & taken to scale
using available Government services.
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Objectives of the Research Project …

8. Cross-sectional nutrition baseline survey in households
with children below 2 years (Aug 11; n=1041)
Restricted randomization of intervention & control villages
(mean height-for-age Z-score)
Nutrition Education on
complementary feeding
(Dec 12 – Jan 14)
Intervention area
(12 clusters)
Cross sectional mid-term survey (Aug 13; n=921)
Food security interventions (Oct 11- Sep 12)
e.g. farmer field schools,
seed & fertilizer distribution,
distribution of fruit seedlings, livestock
Foodsecurity
interventions
1year
NEingroup1
&1monthsin
group2;NE
max9months
Control area
(12 clusters)
Cross sectional impact survey (Aug 14; n=1221)
Longi-
tudinal
study
(n=124)
Focus
Group
discus-
sions,
know-
ledge
tests,
obser-
vations
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9. 9
Primary outcome indicator:
 change in length of children
Secondary outcome indicators:
 achieved Minimum Dietary Diversity (MDD) among children
 achieved Minimum Meal Frequency (MMF) among children
 improved caregiver’s knowledge, attitudes & feeding, hygiene & food
safety practices
Enrolment criteria:
Caregivers with children 6-9 months at first assessment
Intervention area: member of FAO nutrition education group
Control area: resident in FAO intervention villages; matched by sex &
age in days (±14 days)
Assessments: every 3 months for one year = five assessments
Study Design

10. Cross-sectional Surveys
Baseline, Mid-term, & Impact
• Cross-sectional nutrition surveys in 24 EPA sections
in Kasungu & Mzimba Districts
• Study population: mothers/primary caregivers and
children <2 years
• Random selection of 3 villages on section (cluster)
level (PPS) (baseline and mid-term)
• Random selection of 4 villages per section (PPS)
(impact)
• Random selection of participants at village level
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11. • Baseline: August/September 2011 (sample size: height-for-
age z-score)
– IFSN intervention villages
• Mid-term: August/September 2013 (sample size: children’s
dietary diversity)
– Intervention area: nutrition education villages only (Round 1)
– Control area: food security intervention villages only
• Impact: August/September 2014 (sample size: height-for-
age z-score)
– Intervention area: nutrition education villages only
(Round 1, same as in mid-term + 1 additional per section)
– Control area: food security intervention villages only
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Cross-sectional Surveys
Baseline, Mid-term, & Impact

12. Study Population at Baseline, Mid-term, & Impact
Baseline (N=1041)
Aug/Sept 2011
Midterm (N=921)
Aug/Sept 2013
Impact (N=1221)
Aug/Sept 2014
Main characteristics Int. Cont. Int. Cont. Int. Cont.
Percentage (%)
Main income source = farming 73 78 77 81 68 77
Improved drinking water source 77 76 86 83 86 83
Improved sanitation facility 27 31 59 59 50 42
Mean (SD)
HFIAS Score (min-max= 0 – 27) 6.9 ± 6.6 8.8 ± 6.9 4.4 ± 5.9 5.7 ± 6.5
Wealth index (min-max = -6.1 – 13.5) 0.4 ± 3.7 -0.1 ± 3.4 0.1 ± 3.7 -0.5 ± 3.4 0.2 ± 3.7 -0.1 ± 3.9
Years of school education of mother 5.6 ± 3.2 5.2 ± 3.1 6.3 ± 3.1 6.5 ± 2.9 7.0 ± 2.6 6.7 ± 2.9
Int.=Intervention area = food security intervention and nutrition education; Cont.=Control area = food security intervention only
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Access to improved water & sanitation facilities
increased over time
Food security situation improved over time, was
higher in intervention area
Average years of schooling increased over time

13. WHO IYCF Indicators at
Baseline, Mid-term, & Impact
% children 6 to < 24
months receiving …
Baseline
Aug/Sep 2011
(n = 832 )
Midterm
Aug/Sep 2013
(n = 780 )
Impact
Aug/Sep 2014
(n = 977)
Int. Cont. Int. Cont. Int. Cont.
Breast milk 96 93 97 98 96 95
Minimum dietary diversity 63 56 71 49 71 55
Minimum meal frequency 89 80 85 79 91 81
Minimum acceptable diet 58 48 63 43 67 48
Standardised WHO indicators (WHO 2011)
Int.= intervention area = food security and nutrition education
Cont. = control area = food security only
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14. Difference-in-Differences Model
Baseline
Impact
Intervention
Effect
Intervention
Control

15. Child Dietary Diversity Score (CDDS)
3.8
3.6
4.0
3.4
Baseline Impact
Covariates: age of child, maternal education, wealth
Estimatedmean
CDDS
P=0.003
Intervention
Control

16. WHO Indicators: Complementary Feeding
 CDDS significantly increased
• Intervention effect 40%, P=0.003
 MDD (minimum dietary diversity) significantly increased
• Intervention effect 13%, P=0.004
 MMF (minmum meal frequency) already high at baseline
 MAD (minimum acceptable diet) significantly increased
• Intervention effect 12%, P=0.007

17. Children Consuming ASF & Legumes a
Day Before the Survey
0%
20%
40%
60%
80%
Intervention Control Intervention Control Intervention Control
Baseline Midterm Impact
Animal source foods (ASF) Legumes 17

18. P=0.001
ASF Consumption – DiD Model
12%
13%
16%
6%
Intervention
Control
Baseline Impact
Covariates: age of child, maternal education, wealth
Estimatedprevalence
ofASFandegg
consumption
45% 45%
52%
39%
All ASF
Eggs
P=0.005

19. Legumes Consumption – DiD Model
67%
59%
76%
62%
Baseline Impact
Covariates: age of child, maternal education, wealth
Estimatedprevalence
oflegumes
consumption
P=ns
Intervention
Control

20. Mean (SD) height for age z-score
(6-23 months old children, IMCF research area)
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-3.5
-3
-2.5
-2
-1.5
-1
-0.5
0
control intervention control intervention control intervention
Baseline 08/2011 Mid-term 08/2013 Impact 08/2014
Meanheightforagez-score(HAZ)

21. Impact on Height-for-age Z-score (DiD)
Midterm Survey & Impact Survey
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• Midterm Survey: Sign. differences in mean
HAZ between intervention (-0.17) & control (-
0.19) which can be related to the intervention:
food security & nutrition education
• Impact Survey: No sign. differences in mean
HAZ between intervention (-0.17) & control (-
0.18)

22. Conclusions
• Food security interventions & participatory
nutrition education improved children’s
nutritional status at community level
• IFSN nutrition education approach using
local resources has a high potential to
improve dietary diversity of children
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23. IMCF Project Team
Malawi Cambodia
Food security Project IFSN MALIS
Research Institutions Lilongwe University of
Agriculture and Natural
Resources (LUANAR):
Dr C Masangano
Dr B Mtimuni
Dr A Kalimbira
Dr C Nthinda
Mahidol University & NNP
Cambodia:
Dr O Kevanna
Dr P Winichagoon
Dr G Charoonruk
Dr K Sranacharoenpong
Students Ms J Kuchenbecker
Ms G Chiutsi Phiri
et al.
Ms A Reinbott
Mr M Khun
et al.
FAO Headquarters Rome,
Italy
Ms E Muehlhoff, Dr E Westaway,
Ms T. Jeremias, Ms Graz, and
until August 2013: Dr Gina Kennedy
JLU Giessen, Germany Prof. MB Krawinkel, MD, Dr I Jordan,
Dr J Herrmann, Dr E Heil
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24. Registration & Funding
German Clinical Trial Register (DRKS)
https://drks-neu.uniklinik-freiburg.de/drks_web/setLocale_EN.do
The research was conducted within the IMCF Project of
FAO:
http://www.fao.org/ag/humannutrition/nutritioneducation/70106/en/
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