Strategies to Increase Milk Consumption by Young Nepali Children
Condition: Child Malnutrition
MeSH terms: Malnutrition; Child Nutrition Disorders
Study type: Interventional

Summary: 
      Dairy animals are an important source of income, food and nutrition security at the household
      level. However, substandard animal husbandry practices and limited understanding of disease
      prevention and control may limit dairy animal productivity. Interventions to address these
      issues may enhance milk production, substantially improving the well-being of smallholder
      farmers. In addition to increasing household income, greater milk production may improve the
      diet quality of household members, particularly children.

      Previously, the investigators implemented a program in rural Nepal promoting enhanced animal
      husbandry practices (GHP), focusing on mastitis control. Concurrently, the investigators
      found child milk intake was strongly linked to better growth and development. However, milk
      intake was limited and its availability was not examined. The investigators now propose to
      build on these prior activities and examine strategies to increase child milk consumption.
      The investigators plan to introduce a nutrition education program into 200 households (with
      young children) which previously received GHP training. A comparison group of 200 households
      will serve as the control. Household surveys will be conducted at baseline and endline to
      assess (1) household milk production and the sustainability of adoption of GHP routines, (2)
      the relationship of household milk production to child milk consumption, (3) household
      factors influencing child milk consumption (participation in nutrition education, mother's
      education, socioeconomic status, etc.), and (4) longitudinal child growth and development. In
      addition, a pilot study will determine if households can accurately record milk production
      and child milk intake.

      The project is designed to enhance understanding of the links between milk availability and
      child milk consumption in rural Nepal. It aims to explore whether milk consumption is limited
      by availability or other factors (nutrition awareness, socioeconomic status, maternal
      education). Additionally, the investigators will examine if optimization of milk consumption
      by young children can further boost their growth and development, and whether instruction in
      good animal husbandry practice and mastitis control is sustainable. These findings could more
      appropriately and efficiently direct resources to improve child nutrition and development and
      household dairy practices.
    

Detailed description: 
      The study will be conducted in close collaboration with Heifer International Nepal, a
      well-established branch of Heifer International, an international non-government organization
      based in Little Rock, Arkansas. Heifer specializes in community development activities and
      livestock management training; as part of Heifer's activities, participating households
      receive 1 or more dairy animals. The proposed study will take place in 3 districts in western
      Nepal (Bardiya, Surkhet, and Dang) where Heifer has been active and dairy animals have been
      distributed. Households (n=400) will be eligible for participation if there is at least one
      child between the ages of 6-66 months and at least one dairy animal. Household clusters
      (separated geographically) will be randomly assigned to receive either nutrition education or
      to control status (no education). Households assigned to control status will be offered the
      nutrition education after completion of data collection for the proposed project (12 months
      later).

      The participants will be one adult in each household (usually the child's mother), and any
      children in the household between the ages of 6-66 months.

      The study design involves 3 household visits, spaced over 12 months (thus: baseline, 6
      months, and endline). In addition, information about household dairy animal milk production
      will be collected on a monthly basis.

      At the baseline and endline household visits, the mother (or other caretaker) of the target
      child will be asked to respond to a questionnaire. The questionnaire will be based on
      standardized tools developed by "Measure Demographic and Health survey (DHS)", specifically
      the version used in the "2016 Nepal Demographic and Health Survey" conducted by the
      Government of Nepal (Ministry of Health et al. 2017) (Ministry of Health and Population Nepal
      et al. 2012). The questionnaire will address (A) household attributes, (B) child diet, (C)
      child growth, and (D) child development.

      (A) Household attributes: basic demographics, possessions (used to determine wealth score by
      standard principal components analysis), hygiene practices, animal ownership, mother's
      knowledge/attitudes/practices related to child nutrition.

      (B) Child diet: Consumption of animal source foods (ASFs: meat, fish, offal, eggs, or dairy)
      in the past 24 hours by all children in the household (ages 12-60 months) will be recorded
      (Ruel 2003, Steyn et al. 2007), along with the frequency of intake. The quantity of milk and
      other dairy foods ingested will also be determined. In addition, 16 specific foods/food
      groups will be documented (Kennedy et al. 2013). Milk and "other dairy products" (yogurt,
      paneer, cheese, etc.) will be recorded separately. In addition, the number of times in the
      previous week that the child consumed each of the 16 individual food items will be recorded.
      A diet diversity score (DDS) will be constructed by aggregating the food groups into 8
      categories: starchy staples (grains and white potatoes); vitamin-A rich fruits and
      vegetables; other fruits and vegetables; offal, meat, and fish; eggs; legumes, nuts, and
      seeds; milk and dairy products; oils (Swindale et al. 2006).

      (C) Child growth will also be assessed by standard anthropometric techniques (see (Miller et
      al. 2017) for details) using Seca scales and stadiometers and paper measuring tapes (for head
      and mid-upper arm circumferences).

      (D) Child development: relevant sections of the Multiple Indicator Cluster Survey (UNICEF
      2015), a standardized questionnaire developed by UNICEF (and validated in Nepal (Government
      of Nepal 2014)) to assess early child development, will be administered by the enumerator.
      The child's parent (usually the mother), will respond to questions related to child
      literacy/numeracy, gross and fine motor skills, social-emotional development, and learning
      skills. In addition, the age-appropriate version of the Ages and Stages Questionnaire will be
      administered. This simple assessment serves as a screen test for developmental issues by
      asking the child (or if the child is unable or unwilling to participate) to engage in
      developmentally appropriate activities such as completing a puzzle, jumping, scribbling with
      a crayon, or answering simple questions ("How old are you").

      The midline visit will include only child anthropometry and child diet record.
    

Intervention name(s): Community-based nutrition education
Intervention type(s): Other
Intervention description(s): Nutrition education will be included in community development training. The nutrition education will target child nutrition, particularly consumption of animal-source foods and especially milk. The importance of dietary diversity will also be emphasized. Demonstrations of food preparation techniques will also be included in the training.
Allocation: Randomized
Intervention model: Parallel Assignment
Intervention model description: Household clusters (separated geographically) will be randomly assigned to receive either nutrition education or to control status (no education).
Masking: None (Open Label)
Primary purpose: Health Services Research
Keywords: Nepal; ASF consumption