Innovative strategies to reduce malnutrition among children in urban slums, the case of Dhaka, Bangladesh

Abstract

Methods:This study consisting of three distinct stages: (1) a formative study, (2) a randomised control trial (RCT), and (3) a post-intervention acceptability and feasibility study. At first stage, a comprehensive literature review,was conducted to understand the utilisation of fermented foods for improving the growth and gut health of children under five. Additionally, a qualitative exploration using in-depth interviews with slum mothers of infants aged 6-12 months explored the acceptability of yoghurt as an early complementary food and the operational challenges in implementing the intervention. Laboratory experiments were also performed to identify the presence of the recommended number of live bacteria in the homemade study yoghurt before initiating the main trial. The findings from these formative studies informed the development of the yoghurt intervention for this population. In the RCT, a 3-month yoghurt intervention was assessed on 162 infants aged 6-9 months with mild malnutrition [length-for-age z-score (LAZ) ≤ −1 SD and >−2 SD]. They were randomly assigned to one of three groups: nutrition education-only, yoghurt supplementation + nutrition education, or usual care (control group). The primary outcome was changes in LAZ, with secondary outcomes including changes in weight-for-age z-score (WAZ), alterations in dietary diversity in complementary feeding and knowledge regarding infant feeding, and modifications in faecal inflammatory biomarkers. The outcomes were assessed at baseline and 3 months. A longitudinal analysis using mixed-effect models and ANCOVA was conducted to evaluate the time-by-treatment effects on the study outcomes. Finally, in the acceptability and feasibility study, in-depth interviews with mothers were conducted to explore their attitudes and experiences with the yoghurt intervention and assess the overall feasibility of its implementation. Results:The formative study not only shed light on the acceptability of yoghurt as a complementary food but also confirmed the presence of a sufficient quantity of viable beneficial bacteria in the homemade study yoghurt. Complete-case analysis suggested that after the intervention, children in the education-only group improved their LAZ by 0.13 SD (95% CI: -0.13, 0.39; p value 0.32) and children in the yoghurt-plus education group by 0.20 SD (95% CI: -0.06, 0.47; p value 0.13) compared to the control group. Importantly, the yoghurt-plus education group exhibited a more pronounced improvement than the education-only group, but the between- group differences were not statistically significant. Similarly, children who received the yoghurt intervention were 5 times more likely (95% CI: 0.80, 31.80, p value 0.09) to meet the minimum dietary diversity (MDD) score compared to the control group. Both intervention groups demonstrated an increase in dietary diversity in child feeding, with the yoghurt-plus education group surpassing the education-only group. However, these changes did not attain statistical significance. Mothers in the intervention groups showed a significantly greater increase in knowledge regarding nutritious food groups compared to the control group. Among the three tested biomarkers, neopterin reduction reached a significance at a 10% level (p value <0.10) among children in the yoghurt-plus education group compared to the control. The results of the acceptability study unequivocally supported positive attitudes toward yoghurt with various health benefits mentioned by mothers.

Date of Award	2023
Original language	English
Awarding Institution	Western Sydney University
Supervisor	Dafna Merom (Supervisor)