Effectiveness of an educational intervention delivered through the health services to improve nutrition in young children: a cluster-randomised controlled trial
Background: Malnutrition is the underlying cause of half of child mortality. Many programmes attempt to remedy this issue but there is a lack of evidence on effective ways to decrease child malnutrition.
Methods: We did a cluster-randomized trial of an educational intervention in a poor periurban area or shanty town (Trujillo) in Peru. Guided by formative research, the intervention aimed to enhance the quality and coverage of existing nutrition education and to introduce an accreditation system in six government health facilities compared with six control facilities. The primary outcome measure was growth that was measured by weight, length, and Z scores for weight-for-age and length-for-age at age 18 months. Main secondary outcomes were the percentage of children receiving recommended feeding practices and the 24-h dietary intake of energy, iron, and zinc from complementary food at ages 6, 9, 12, and 18 months. Analysis was by intention to treat.
Findings: We enrolled a birth cohort of 187 infants from the catchment areas of intervention centres and 190 from control areas. Caregivers in intervention areas were more likely to report receiving nutrition advice from the health service than were caregivers in control health facilities (16 of 31, 52% vs. 9 of 37, 24%; P=0.02). At six months, more babies in intervention areas were fed nutrient-dense thick foods at lunch (a recommended complementary feeding practice) than were controls (48 of 157, 31% vs. 29 of 147, 20%; difference between groups 19, 11%; P=0.03). Fewer children in intervention areas failed to meet dietary requirements for energy (eight months: 30 of 170, 18% vs. 45 of 167, 27%; P=0.04; 12 months: 64 of 168, 38% vs. 82 of 167, 49%; P=0.043), iron (eight months: 155 of 170, 91% vs. 161 of 167, 96%; nine months: 152 of 163, 93% vs. 165 of 166, 99%; P=0.047), and zinc (nine months: 125 of 163, 77% vs. 145 of 166, 87%; P=0.012) than did controls. Children in control areas were more likely to have stunted growth (ie, length for age less than 2 SD below the reference population median) at 18 months than children in intervention groups (26 of 165, 16% vs. 8 of 171, 5%; adjusted odds ratio 3.04; 95% confidence interval 1.21-7.64). Adjusted mean changes in weight gain, length gain, and Z scores were all significantly better in the intervention area than in the control area.
Interpretation: Improvement of nutrition education delivered through health services can decrease the prevalence of stunted growth in childhood in areas where access to food is not a limiting factor.