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How immediate and significant is the outcome of training on diversified diets, hygiene and food safety? An effort to mitigate child undernutrition in rural Malawi

  • Anitha Seetha (a1), Takuji W Tsusaka (a1), Timalizge W Munthali (a2), Maggie Musukwa (a2), Agnes Mwangwela (a2), Zione Kalumikiza (a2), Tinna Manani (a2), Lizzie Kachulu (a1), Nelson Kumwenda (a1), Mike Musoke (a1) and Patrick Okori (a1)...

The present study examined the impacts of training on nutrition, hygiene and food safety designed by the Nutrition Working Group, Child Survival Collaborations and Resources Group (CORE).


Adapted from the 21d Positive Deviance/Hearth model, mothers were trained on the subjects of appropriate complementary feeding, water, sanitation and hygiene (WASH) practices, and aflatoxin contamination in food. To assess the impacts on child undernutrition, a randomised controlled trial was implemented on a sample of 179 mothers and their children (<2 years old) in two districts of Malawi, namely Mzimba and Balaka.


A 21d intensive learning-by-doing process using the positive deviance approach.


Malawian children and mothers.


Difference-in-difference panel regression analysis revealed that the impacts of the comprehensive training were positive and statistically significant on the Z-scores for wasting and underweight, where the effects increased constantly over time within the 21d time frame. As for stunting, the coefficients were not statistically significant during the 21d programme, although the level of significance started increasing in 2 weeks, indicating that stunting should also be alleviated in a slightly longer time horizon.


The study clearly suggests that comprehensive training immediately guides mothers into improved dietary and hygiene practices, and that improved practices take immediate and progressive effects in ameliorating children’s undernutrition.

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1. Lombard, JM (2014) Mycotoxin exposure and infant and young child growth in Africa: what do we know? Ann Nutr Metab 64, 4252.
2. National Statistical Office (2014) Malawi MDG (Millennium Development Goals) Endline Survey 2014, Key Findings. Zomba, Malawi: National Statistical Office.
3. Mangili, A, Murman, DH, Zampini, AM et al. (2006) Nutrition and HIV infection: review of weight loss and wasting in the era of highly active antiretroviral therapy from the nutrition for healthy living cohort. Clin Infect Dis 42, 836842.
4. Mitch, WE & Goldberg, AL (1996) Mechanisms of muscle wasting – the role of the ubiquitin–proteasome pathway. N Engl J Med 335, 18971905.
5. Smith, LE, Stoltzfus, RJ & Prendergast, A (2012) Food chain mycotoxin exposure, gut health and impaired growth: a conceptual framework. Adv Nutr 3, 526531.
6. Neumann, CG & Harrison, GG (1994) Onset and evolution of stunting in infants and children. Examples from the Human Nutrition Collaborative Research Support Program. Kenya and Egypt studies. Eur J Clin Nutr 48, 90102.
7. Nandy, S & Miranda, JJ (2008) Overlooking undernutrition? Using a composite index of anthropometric failure to assess how underweight misses and misleads the assessment of undernutrition in young children. Soc Sci Med 66, 19631966.
8. Prasanna, BM, Vasal, SK, Kassahun, B et al. (2001) Quality protein maize. Curr Sci 81, 13081319.
9. Malawi Vulnerability Assessment Committee (2014) Market Assessment Report. Lilongwe: Government of Malawi.
10. Messina, AJ (1999) Legumes and soybeans: overview of their nutritional profiles and health effects. Am J Clin Nutr 70, Suppl. 3, 439S450S.
11. Okpala, LC & Okoli, EC (2011) Nutritional evaluation of cookies produced from pigeon pea, cocoyam and sorghum flour blends. Afr J Biotechnol 10, 433438.
12. Kannan, S (2010) Finger millet in nutrition transition: an infant weaning food ingredient with chronic disease preventive potential. Br J Nutr 104, 17331734.
13. Snapp, SS & Fisher, M (2015) ‘Filling the maize basket’ supports crop diversity and quality of household diet in Malawi. Food Sec 7, 8396.
14. Mlotha, V, Mwangwela, AM, Kasapila, W et al. (2015) Glycemic responses to maize flour stiff porridges prepared using local recipes in Malawi. Food Sci Nutr 4, 322328.
15. Wild, CP & Gong, YY (2010) Mycotoxins and human disease: a largely ignored global health issue. Carcinogenesis 31, 7182.
16. Williams, JH, Phillips, TD, Jolly, PE et al. (2004) Human aflatoxicosis in developing countries: a review of toxicology, exposure, potential health consequences, and interventions. Am J Clin Nutr 80, 11061122.
17. Turner, PC (2013) The molecular epidemiology of chronic aflatoxin driven impaired child growth. Scientifica 2013, 152879.
18. Williams, JH, Grubb, JA, Davis, JW et al. (2010) HIV and hepatocellular and esophageal carcinomas related to consumption of mycotoxin-prone foods in sub-Saharan Africa. Am J Clin Nutr 92, 154160.
19. Keenan, J, Jolly, P, Preko, P et al. (2011) Association between aflatoxin B1–albumin adduct levels and tuberculosis infection among HIV+ Ghanaians. Arch Clin Microbiol 2, issue 3, doi: 10:3823/230.
20. Matumba, L, Monjerezi, M, Chirwa, E et al. (2009) Natural occurrence of AFB1 in maize and effect of traditional maize flour production on AFB1 reduction in Malawi. Afr J Food Sci 3, 413425.
21. Monyo, ES, Njoroge, SMC, Coe, R et al. (2012) Occurrence and distribution of aflatoxin contamination in groundnuts (Arachis hypogaea L) and population density of aflatoxigenic Aspergilli in Malawi. Crop Protect 42, 149155.
22. Atehnkeng, J, Ojiambo, PS, Cotty, PJ et al. (2014) Field efficacy of a mixture of atoxigenic Aspergillus flavus Link:Fr vegetative compatibility groups in preventing aflatoxin contamination in maize (Zea mays L.). Biol Contr 72, 6270.
23. Cotty, PJ, Bayman, P, Egcl, DS et al. (1994) Agriculture, aflatoxins, and Aspergillus . In The Genus Aspergillus: From Taxonomy and Genetics to Industrial Applications, FEMS Symposium No. 69, pp. 127 [KA Powell, A Renwick and JF Peberdy, editors]. New York: Plenum Press.
24. Partnership for Aflatoxin Control in Africa (2013) PACA Strategy 2013–2022. Addis Ababa: PACA, African Union Commission.
25. Velleman, Y & Pugh, I (2015) Under-Nutrition and Water, Sanitation and Hygiene. UK: WaterAid and SHARE (Sanitation and Applied Research for Equity consortium).
26. Berggren, G, Alvarez, M & Genece, E (1984) The Nutrition Demonstration Foyer: A Model for Combating Malnutrition in Haiti. Boston, MA: Massachusetts Institute of Technology.
27. Zeitlin, M, Ghassemi, H & Mansour, M (1990) Positive Deviance in Child Nutrition – With Emphasis on Psychosocial and Behavioural Aspects and Implications for Development. Tokyo: United Nations University.
28. Bullen, PB (2012) A multiple case study analysis of the positive deviance approach in community health. PhD Dissertation, Walden University.
29. Bullen, PAB (2011) The positive deviance/hearth approach to reducing child malnutrition: systematic review. Trop Med Int Health 16, 13541366.
30. Le Roux, IM, le Roux, K, Mbeutu, K et al. (2011) A randomised controlled trial of home visits by neighborhood mentor mothers to improve children’s nutrition in South Africa. Vulnerable Child Youth Stud 6, 91102.
31. Ashworth, A & Ferguson, E (2008) Dietary counselling in the management of moderate malnourishment in children. Food Nutr Bull 30, 3 Suppl., S405S433.
32. Nanchukwa, KD (2007) Giving chance to indigenous knowledge in developing sustainable nutrition improvement interventions. In Proceedings of 2nd International AAAE Conference, Accra, Ghana, 18–22 August 2007, pp. 589591. Nairobi: African Association of Agricultural Economists.
33. Appoh, LY & Krekling, S (2005) Maternal nutritional knowledge and child nutritional status in the Volta region of Ghana. Matern Child Nutr 1, 100110.
34. Marriott, BP, White, A, Hadden, L et al. (2012) World Health Organization (WHO) infant and young child feeding indicators: associations with growth measures in 14 low-income countries. Matern Child Nutr 8, 354370.
35. Brundtland, GH (2000) Nutrition and infection: malnutrition and mortality in public health. Nutr Rev 58, 2 Pt 2, S1S4.
36. Tchana, AN, Moundipa, PF & Tchouanguep, FM (2010) Aflatoxin contamination in food and body fluids in relation to malnutrition and cancer status in Cameroon. Int J Environ Res Public Health 1, 178188.
37. Gong, YY, Cardwell, K, Hounsa, A et al. (2002) Dietary aflatoxin exposure and impaired growth in young children from Benin and Togo: cross sectional study. BMJ 325, 2021.
38. Wright, RC (1986) The seasonality of bacterial quality of water in a tropical developing country (Sierra Leone). J Hyg (Lond) 96, 7582.
39. Kennedy, G, Ballard, T & Dop, M (2010) Guidelines for Measuring Household and Individual Dietary Diversity. Rome: FAO.
40. Swindale, A & Bilinsky, P (2006) Household Dietary Diversity Score (HDDS) for Measurement of Household Food Access: Indicator Guide (v.2). Washington, DC: FHI 360/FANTA.
41. Seetharaman, N, Chacko, TV, Shankar, SLR et al. (2007) Measuring malnutrition – the role of Z scores and the composite index of anthropometric failure (CIAF). Indian J Community Med 32, 3539.
42. Blössner, M & De Onis, M (2005) Malnutrition: Quantifying the Health Impact at National and Local Levels. WHO Environmental Burden of Disease Series no. 12. Geneva: WHO.
43. Nutrition Work Group, Child Survival Collaborations, and Resources Group (2002) Positive Deviance/Hearth: A Resource Guide for Sustainably Rehabilitating Malnourished Children. Washington, DC: CORE.
44. Donald, SG & Lang, K (2007) Inference with difference-in-differences and other panel data. Rev Econom Stat 89, 221233.
45. Lechner, M (2011) The estimation of causal effects by difference-in-difference methods. Found Trends Econom 4, 165224.
46. Tsusaka, TW, Orr, A, Msere, HW et al. (2016) Do Commercialization and Mechanization of a ‘Women’s Crop’ Disempower Women Farmers? Evidence from Zambia and Malawi. Boston, MA: Agricultural & Applied Economics Association.
47. Munthali, WM, Charlie, HJ, Kachulu, L et al. (2016) How to Reduce Aflatoxin Contamination in Groundnuts and Maize: A Guide for Extension Workers. Patancheru, India: ICRISAT.
48. Watson, S, Gong, YY & Routledge, M (2015) Interventions targeting child undernutrition in developing countries may be undermined by dietary exposure to aflatoxin. Crit Rev Food Sci Nutr 57, 19631975.
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