Behaviour Change Communication (BCC) intervention programmes often lack documentation of successful processes. This manuscript aims to describe the development of Program Impact Pathway (PIP) using Theory of Change (ToC) approach for a mHealth BCC intervention titled ‘Mobile Solutions Aiding Knowledge for Health Improvement (M-SAKHI)’ aimed at reducing stunting in infants at 18 months of age.

The PIP was developed using ToC to design the intervention and plan its implementation. Literature review and data from previous pilots helped to identify health service gaps that needed to be addressed by the PIP of this intervention.

M-SAKHI was implemented in 244 villages under governance of forty primary health centres of Nagpur and Bhandara districts of eastern Maharashtra in central India.

The study investigators and the public health stakeholders participated in developing the PIP. M-SAKHI evaluation study recruited 2501 pregnant women who were followed up through delivery until their infants were 18 months old.

The PIP was developed, and it identified the following pathways for the final impact: (1) improving maternal and infant nutrition, (2) early recognition of maternal and infant danger signs, (3) improving access and utilisation to healthcare services, (4) improving hygiene, sanitation and immunisation practices, and (5) improving implementation and service delivery of community health workers through their training, monitoring and supervision in real time.

This paper will illustrate the significance of development of PIP for M-SAKHI. It can aid other community-based programmes to design their PIP for nutrition-based BCC interventions.

The study’s objective was to investigate multiple underlying social, economic and agricultural determinants of stunting among under-five children in three distinct ecological areas in rural Myanmar.

Repeated cross-sectional surveys in three states of Myanmar.

Rural households in Chin (mountainous), Magway (plains) and Ayeyarwady (delta).

From two purposively selected adjacent townships in each state, we randomly selected twenty villages and, in each village, thirty households with under-five children. Households in the first survey in 2016 were revisited in late 2017 to capture seasonal variations.

Stunting increased from 40·4 % to 42·0 %, with the highest stunting prevalence in Chin state (62·4%). Univariate Poisson regression showed factors contributing to child stunting varied across the regions. Adjusted Poisson regression models showed that child’s age and short maternal stature (aRR = 1·14 for Chin, aRR = 1·89 for Magway and aRR = 1·86 for Ayeyarwady) were consistently associated with child stunting across three areas. For Chin, village-level indicators such as crop consumption (aRR = 1·18), crop diversity (aRR = 0·82) and land ownership (aRR = 0·89) were significantly associated with stunting. In Magway, the number of household members (aRR = 1·92), wealth status (aRR = 0·46), food security status (aRR = 1·14), land ownership (aRR = 0·85) and in Ayeyarwady, women’s decision-making (aRR = 0·67) and indicators related to hygiene (aRR = 1·13) and sanitation (aRR = 1·45) were associated with stunting.

Area-specific factors were associated with stunting. Maternal short stature and child age were consistent determinants of stunting. A multi-sectoral local approach, including improvements in transport, is needed to address the intergenerational malnutrition problem.

Adolescence is a period of life when dietary patterns and nutrient intakes may greatly influence adult fatness. This study assesses the tracking of energy and nutrient intakes of Ho Chi Minh City adolescents over 5 years. It explores the possible relationships between energy and the percentage of energy from macronutrients with BMI.

Height, weight, time spent on physical activity, screen time and dietary intakes were collected annually between 2004 and 2009 among 752 junior high school students with a mean age of 11·87 years at baseline. The tracking was investigated using correlation coefficients and weighted kappa statistics (k) for repeated measurements. Mixed effect models were used to investigate the association between energy intakes and percentage energy from macronutrients with BMI.

There were increases in the mean BMI annually, but greater in boys than in girls. Correlation coefficients (0·2 < r < 0·4) between participants’ intakes at baseline and 5-year follow-up suggest moderate tracking. Extended kappa values were lowest for energy from carbohydrate (CHO) in both girls and boys (k = 0·18 & 0·24, respectively), and highest for protein in girls (k = 0·47) and fat in boys (k = 0·48). The multilevel models showed the following variables significantly correlated with BMI: CHO, fat, percentage of energy from CHO, fat, time spent for moderate to vigorous physical activity, screen time, age and sex.

The poor to fair tracking observed in this cohort suggests that individual dietary patterns exhibited in the first year are unlikely to predict energy and nutrient intakes in the fifth year.

To examine minimum dietary diversity (MDD) trends and determinants among children aged 6–23 months.

Secondary analysis of the Indonesia Demographic and Health Surveys (IDHS) between 2007 and 2017. The primary outcome was MDD, the consumption of at least five out of eight food groups (MDD-8). We included a total of 5015 (IDHS 2007), 5050 (IDHS 2007) and 4925 (IDHS 2017) children aged 6 to 23 months to estimate trends of MDD-8 and to identify factors associated with MDD-8. We used multiple logistic regression analysis adjusted for the complex sampling design to investigate the association between the study factors and MDD-8.

Indonesia.

A total of 14 990 children aged 6–23 months.

Over the 10 years, the percentage of children who consumed a diversified diet was 53·1 % in 2007, 51·7 % in 2012 and 53·7 % in 2017. Multivariate analyses showed that older age children, higher maternal education, maternal weekly access to media, paternal non-agricultural occupation, history of at least four antenatal care visits and wealthier households were associated with the increased odds of MDD-8. Children living in rural areas, Sulawesi and Eastern Indonesia, were less likely to eat a diversified diet.

The proportion of children meeting MDD-8 has stagnated in the last decade. Child, parental, health care, household and community factors are associated with MDD-8. Therefore, nutrition education programmes and behaviour change communication activities should target mothers and families from socio-economically and geographically disadvantaged populations.

To explore complementary feeding practices and identify potential risk factors associated with inadequate complementary feeding practices in Ghana by using the newly developed WHO infant feeding indicators and data from the nationally representative 2008 Ghana Demographic and Health Survey.

The source of data for the analysis was the 2008 Ghana Demographic and Health Survey. Analysis of the factors associated with inadequate complementary feeding, using individual-, household- and community-level determinants, was done by performing multiple logistic regression modelling.

Ghana.

Children (n 822) aged 6–23 months.

The prevalence of the introduction of solid, semi-solid or soft foods among infants aged 6–8 months was 72·6 % (95 % CI 64·6 %, 79·3 %). The proportion of children aged 6–23 months who met the minimum meal frequency and dietary diversity for breast-fed and non-breast-fed children was 46·0 % (95 % CI 42·3 %, 49·9 %) and 51·4 % (95 % CI 47·4 %, 55·3 %) respectively and the prevalence of minimum acceptable diet for breast-fed children was 29·9 % (95 % CI 26·1 %, 34·1 %). Multivariate analysis revealed that children from the other administrative regions were less likely to meet minimum dietary diversity, meal frequency and acceptable diet than those from the Volta region. Household poverty, children whose mothers perceived their size to be smaller than average and children who were delivered at home were significantly less likely to meet the minimum dietary diversity requirement; and children whose mothers did not have any postnatal check-ups were significantly less likely to meet the requirement for minimum acceptable diet. Complementary feeding was significantly lower in infants from illiterate mothers (adjusted OR=3·55; 95 % CI 1·05, 12·02).

The prevalence of complementary feeding among children in Ghana is still below the WHO-recommended standard of 90 % coverage. Non-attendance of postnatal check-up by mothers, cultural beliefs and habits, household poverty, home delivery of babies and non-Christian mothers were the most important risk factors for inadequate complementary feeding practices. Therefore, nutrition educational interventions to improve complementary feeding practices should target these factors in order to achieve the fourth Millennium Development Goal.

Exclusive breast-feeding is estimated to reduce infant mortality in low-income countries by up to 13 %. The aim of the present study was to determine the risk factors associated with suboptimal breast-feeding practices in Pakistan.

A cross-sectional study using data extracted from the multistage cluster sample survey of the Pakistan Demographic and Health Survey 2006–2007.

A nationally representative sample of households.

Last-born alive children aged 0–23 months (total weighted sample size 3103).

The prevalences of timely initiation of breast-feeding, bottle-feeding in children aged 0–23 months, exclusive breast-feeding and predominant breast-feeding in infants aged 0–5 months were 27·3 %, 32·1 %, 37·1 % and 18·7 %, respectively. Multivariate analysis indicated that working mothers (OR = 1·48, 95 % CI 1·16, 1·87; P = 0·001) and mothers who delivered by Caesarean section (OR = 1·95, 95 % CI 1·30, 2·90; P = 0·001) had significantly higher odds for no timely initiation of breast-feeding. Mothers from North West Frontier Province were significantly less likely (OR = 0·37, 95 % CI 0·23, 0·59; P < 0·001) not to breast-feed their babies exclusively. Mothers delivered by traditional birth attendants had significantly higher odds to predominantly breast-feed their babies (OR = 1·96, 95 % CI 1·18, 3·24; P = 0·009). The odds of being bottle-fed was significantly higher in infants whose mothers had four or more antenatal clinic visits (OR = 1·93, 95 % CI 1·46, 2·55; P < 0·001) and belonged to the richest wealth quintile (OR = 2·41, 95 % CI 1·62, 3·58; P < 0·001).

The majority of Pakistani mothers have suboptimal breast-feeding practices. To gain the full benefits of breast-feeding for child health and nutrition, there is an urgent need to develop interventions to improve the rates of exclusive breast-feeding.

The present study aimed to assess complementary feeding practices and identify the potential risk factors associated with inappropriate complementary feeding in Indonesia for a nationally representative sample of births from 2004 to 2007.

The data source for the analysis was the 2007 Indonesia Demographic and Health Survey. Multiple logistic regression was performed to analyse the factors associated with complementary feeding, using individual-, household- and community-level determinants.

Indonesia.

Children (n 4604) aged 6–23 months.

Multivariate analysis revealed that infants from poor households were significantly less likely to be introduced to complementary feeding (adjusted odds ratio, AOR = 4·32; 95 % CI 1·46, 12·80) and meet the minimum dietary diversity (AOR = 1·76; 95 % CI 1·16, 2·68). Mother's education (AOR for no education in dietary diversity = 1·92; 95 % CI 1·09, 3·38; AOR for no education in meal frequency = 2·03; 95 % CI 1·13, 3·64; AOR for no education in acceptable diet = 3·84; 95 % CI 2·07, 7·12), residence and decreased age of the infant were negatively associated with minimum dietary diversity, minimum meal frequency and an acceptable diet. Infants aged 6–11 months were also significantly less likely to meet minimum dietary diversity (AOR = 6·36; 95 % CI 4·73, 8·56), minimum meal frequency (AOR = 2·30; 95 % CI 1·79, 2·96) and minimum acceptable diet (AOR = 2·27; 95 % CI 1·67, 3·09). All geographical regions compared with Sumatra were more likely to give the recommended meal frequency and an acceptable diet to breast-fed children.

Public health interventions to improve complementary feeding should address individual-, household- and community-level factors which significantly influence the introduction of complementary feeding. Complementary feeding intervention programmes in Indonesia should ensure that restraints on families with low socio-economic status are addressed. Infants aged 6–11 months and mothers with low education levels may also need special focus. Promotion strategies should also target the health-care delivery system and the media.

To compare infant and young child feeding practices in children aged 0–23 months across nine East and Southeast Asian countries.

Secondary analyses of cross-sectional data from available Demographic and Health Surveys (DHS; Indonesia, Philippines, Timor-Leste, Cambodia and Vietnam), Multiple Indicator Country Surveys (Lao People's Democratic Republic (Lao PDR) and Myanmar) and national nutrition surveys (Democratic People’s Republic of Korea (DPR Korea) and Mongolia) conducted between 2000 and 2005.

Seven countries from Southeast Asia and two from East Asia.

Children aged 0–23 months with samples ranging from 826 to 5610 for DHS, and from 477 to 5860 for non-DHS data.

More than 93 % of infants were ever breast-fed, and over 75 % were currently breast-fed except in the Philippines. Timely initiation of breast-feeding varied from 32 % in Indonesia to 46 % in Timor-Leste. Exclusive breast-feeding (EBF) rate in infants under 6 months of age ranged from 11 % in Myanmar to 60 % in Cambodia. EBF rates were also low in Vietnam (15·5 %) and Lao PDR (23 %), and varied between 30 % and 40 % in Indonesia, Philippines and Timor-Leste. The proportion of infants under 6 months of age who were given breast milk with non-milk liquids was high except in Indonesia and Timor-Leste. Bottle-feeding rates were lower in DPR Korea (3 %), Lao PDR (6 %) and Myanmar (6 %) and higher in the Philippines (49 %) and Mongolia (31 %). Timely complementary-feeding rate varied widely across countries (6–99 %).

All the countries studied should make greater efforts to improve timely initiation of breast-feeding and EBF for 6 months. Measures should be taken to reduce high bottle-feeding rate in the Philippines, Mongolia, Indonesia and Vietnam, and improve complementary-feeding rate in Lao PDR, Myanmar, DPR Korea and Philippines.

The present study evaluates the reliability and validity of an FFQ designed for use with adolescents in urban Vietnam.

A cohort study was conducted between December 2003 and June 2004. The FFQ was administered three times over a 6-month period (FFQ 1–3) and nutrient intakes were compared to those obtained from four 24 h recalls collected over the same period (24 h recalls 1–4) using crude, energy-adjusted and de-attenuated correlation coefficients. The level of agreement between the two measurements was also evaluated with Bland–Altman analysis. The percentage of nutrient intakes classified within one quintile, as well as quadratic-weighted kappa statistics, were calculated.

Ho Chi Minh City, Vietnam.

A total of 180 students were recruited in three junior high schools.

Coefficients ranged from 0·22 for retinol to 0·78 for fibre for short-term reliability, and from 0·30 for retinol to 0·81 for zinc for long-term reliability. Coefficients for nutrient intakes between the mean of the three FFQ and mean of four 24 h recalls were mostly around 0·40, but higher for energy-adjusted nutrients. After allowing for within-person variation, the mean coefficient was 0·52 for macronutrients and 0·46 for micronutrients. There were a relatively high proportion of nutrient intakes classified within one quintile and a small number grossly misclassified. Kappa values shows ‘fair’ to ‘good’ agreement for all food/nutrient categories, while the Bland–Altman plots indicated that the FFQ is accurate in assessing nutrient intake at a group level.

This newly developed FFQ is a valid tool for measuring nutrient intake in adolescents in urban Vietnam.

To assess the trends in overweight and obesity in pre-school children in urban areas of Ho Chi Minh City (HCMC), Vietnam, over the period 2002 to 2005.

Two cross-sectional studies were conducted in 2002 and 2005. Multistage cluster sampling was used in both surveys to select the subjects. Sociodemographic information was collected using a self-administered questionnaire given to parents in 2002 and using an interview-administered questionnaire to parents in 2005. Weight and height were measured using the same standard methods in both surveys. BMI (kg/m2) was calculated and overweight/obesity was defined using the age- and sex-specific BMI cut-off points proposed by the International Obesity Taskforce.

Children aged 4 to 5 years, attending pre-schools in urban areas of HCMC, Vietnam, in 2002 (n 492) and 2005 (n 670).

The prevalence of overweight and obesity almost doubled from 2002 to 2005 (21·4 % and 36·8 %, respectively). The increase was more evident in less wealthy districts than in wealthy districts. The proportion of boys classified as obese in 2005 (22·5 %) was three times that in 2002 (6·9 %).

The prevalence of overweight and obesity has increased rapidly in children aged 4 to 5 years in urban areas, and especially in less wealthy districts, over a 3-year period. These results signal an urgent need for prevention programmes to control and reverse this rapid upward trend in overweight and obesity in young children in HCMC.

To develop a composite index to describe the overall breast-feeding performance of infants < 6 months of age; and, using this index, to identify the factors associated with poor breast-feeding practices and the association between breast-feeding and infant morbidity.

The 2003 Demographic and Health Survey was a multi-stage cluster sample survey of 4320 households in Timor-Leste which covered 573 infants aged < 6 months. Breast-feeding Performance Index (BPI) was constructed by allocating one point for each of seven infant feeding practices: first suckling within an hour of birth; absence of prelacteals; non-use of feeding bottles; current breast-feeding; not receiving liquids; not receiving formula or other milk; and not receiving solids in the last 24 hours. BPI was treated as the dependent variable in univariate and multivariate analyses to identify the factors associated with poor breast-feeding.

Exclusive breast-feeding rate was 29.9%. The BPI (mean 4.4, standard deviation 1.77) was categorised as low, average and high according to tertiles. Multivariate analysis indicated that infants from the richest households were 1.70 (95% confidence interval (CI) 1.04–2.77) times more likely to have ‘low BPI’ than the poorest. Maternal BMI < 18.5 kg m− 2 was predictive of poor breast-feeding (odds ratio = 1.79; 95% CI 1.27–2.52). In the ‘low’ BPI group, the incidence of diarrhoea (13.4%) and acute respiratory infections (20.7%) during the previous two weeks was significantly higher than in ‘average’ (4.3 and 9.3%) and ‘high’ BPI groups (4.6 and 5.5%).

Creating a composite index to assess the overall breast-feeding performance among infants < 6 months of age is feasible. BPI can be effectively used to identify target groups for breast-feeding promotion interventions.

We conducted an intervention study to assess the impact of the use of an alcohol-chlorhexidine-based hand sanitizer on surgical site infection (SSI) rates among neurosurgical patients in Ho Chi Minh City, Vietnam.

A quasi-experimental study with an untreated control group and assessment of neurosurgical patients admitted to 2 neurosurgical wards at Cho Ray Hospital between July 11 and August 15, 2000 (before the intervention), and July 14 and August 18, 2001 (after the intervention). A hand sanitizer with 70% isopropyl alcohol and 0.5% Chlorhexidine gluconate was introduced, and healthcare workers were trained in its use on ward A in September 2000. No intervention was made in ward B. Centers for Disease Control and Prevention definitions of SSI were used. Patient SSI data were collected on standardized forms and were analyzed using Stata software (Stata).

A total of 786 patients were enrolled: 377 in the period before intervention (156 in ward A and 221 in ward B) and 409 in the period after intervention (159 in ward A and 250 in ward B). On ward A after the intervention, the SSI rate was reduced by 54% (from 8.3% to 3.8%; P = .09), and more than half of superficial SSIs were eliminated (7 of 13 vs 0 of 6 in ward B; P = .007). On ward B, the SSI rate increased by 22% (from 7.2% to 9.2%; P = .8). In patients without SSI, the median postoperative length of stay and the duration of antimicrobial use were reduced on ward A (both from 8 to 6 days; P <.001) but not on ward B.

Our study demonstrates that introduction of a hand sanitizer can both reduce SSI rates in neurosurgical patients, with particular impact on superficial SSIs, and reduce the overall postoperative length of stay and the duration of antimicrobial use. Hand hygiene programs in developing countries are likely to reduce SSI rates and improve patient outcomes.

(1) To determine the reliability and validity of a food-frequency questionnaire (FFQ) for use in epidemiological research in postmenopausal women; and (2) to compare the volume estimation (VE) and weight estimation (WE) method of administration of this questionnaire.

An initial list of foods was derived and modified after pre-testing in 22 subjects. Test-retest reliability was assessed in 21 subjects who had repeat administrations of the questionnaire 14 days apart (FFQ1, FFQ2). The validity of the FFQ was assessed by comparing nutrient intakes with those from a 4-day food record.

Chengdu, People's Republic of China.

Twenty-two postmenopausal women (50–70 years) were recruited from The Second University Hospital, West China University of Medical Sciences, Chengdu and participated in the pre-test. Another 21 women (50–70 years) were randomly selected from the general population of all five districts of Chengdu and participated in the reliability and validity sub-studies.

Energy, protein, carbohydrate, magnesium and sodium intakes in this sample were less than the Recommended Dietary Allowances (RDAs) for 45–70-year-old women in China. Intake of non-cooking fat was higher than the Chinese RDA. Pearson correlation coefficients and intra-class correlation coefficients (ICCs) for reliability of the VE FFQ ranged from 0.51 to 0.85 and from 0.51 to 0.81, respectively; for the WE FFQ, they ranged from 0.22 to 0.86 and from 0.21 to 0.81. Correlation coefficients and ICCs for validity of the WE FFQ ranged from 0.36 to 0.69 and from 0.34 to 0.57, respectively; corresponding values for the VE FFQ were −0.30 to 0.65 and −0.14 to 0.65.

Both the VE and WE FFQs were reliable and valid except for sodium intake. The VE FFQ provided more valid estimates of nutrient intakes than did the WE FFQ.