The Effect of Double Duty Interventions on Double Burden of Malnutrition Among School Adolescents in Ethiopia
Condition: Malnutrition; Degree, Moderate; Diet Habit; Undernutrition; Overnutrition; Underweight; Overweight
MeSH terms: Overweight; Malnutrition; Overnutrition; Thinness
Study type: Interventional

Summary: 
      The goal of this cluster randomized controlled trial is to determine the effect of double
      duty interventions on double burden of malnutrition, dietary diversity score, and frequency
      of morbidity among secondary school adolescents in Debre Berhan City, Ethiopia. The main aim
      is to answer the following questions.

        1. What is the effect of double duty interventions on double burden of malnutrition among
           secondary school adolescents?

        2. What is the effect of double duty interventions on dietary diversity score among
           secondary school adolescents?

        3. What is the effect of double duty interventions on among secondary school adolescents?
    

Detailed description: 
      Introduction Double Burden of Malnutrition (DBM) is the simultaneous coexistence of
      undernutrition along with overweight and obesity within the same individuals, households, and
      populations at the national and international levels across the life course. For example,
      when DBM exists at the individual level, it can be occurring in the form of obesity with
      deficiency of one or more vitamins and minerals, or overweight in an adult who was stunted
      during childhood. Similarly, at the household level, it may be manifest in the forms of an
      overweight or anemic woman with underweight adolescents or grandparent. When it exists at the
      population level, the prevalence of both undernutrition and overweight/obesity can occur in
      the same community, nation, or region.

      Adolescence is a critical period in the life-course of individuals next to infancy due to
      highly increased growth and development. It is ranging from 10 to 19 years and is a
      transition period from childhood to adulthood according to WHO. It is a period in which
      developmental effects related to puberty and brain development lead to new sets of diets, and
      also a time when increased nutrient intake is required for their rapid growth.

      Every person obtains the social, physical, emotional, cognitive, and economic resources that
      are the groundwork for later life healthiness and welfare during adolescence. These resources
      outline paths of adolescents into the succeeding generations. Therefore, strategies,
      interventions, and investments in adolescent health and wellbeing bring benefits today, for
      decades to come, and for the next generation.

      Double-duty interventions (DDIs) are interventions that have the potential to simultaneously
      tackle the burden of both undernutrition and overnutrition or diet-related NCDs in a
      comprehensive manner. These interventions can be achieved in three ways. First, though not
      harming the existing interventions on malnutrition. Second, by retrofitting the existing
      nutrition interventions to address all sorts of malnutrition. Third, through the development
      of de novo integrated interventions (starting from the beginning, anew, or a new) aimed at
      the DBM. These actions reflecting the shared drivers and platforms of contrasting forms of
      malnutrition.

      Double-duty interventions also have the potential to improve nutrition outcomes across the
      spectrum of malnutrition through integrated initiatives, policies, and programs. It is not a
      zero-sum game in addressing contrasted and confounded forms of malnutrition in the global
      population. According to WHO 2017 policy brief, double-duty actions include about ten
      packages. These packages are categorized as health services packages, social safety nets
      packages, educational settings packages, agriculture, food systems, and food environments
      packages.

      These selected potential candidates for double-duty interventions from each setting can be
      summarized into four points. These interventions are optimized strong education and nutrition
      behavior change communication focused on promotion of healthy diets (adequate adolescent
      nutrition, dietary diversity), physical activity (doing proper physical exercise, avoiding
      sitting for log time), prevent undue harm from energy-dense foods (avoiding junk processed
      foods, avoiding fizzy sweetened drinks, street fast foods, chips, salt, sugar etc.), and
      regulations on marketing foods from the customer side (e.g., buying of packed foods
      frequently). For this project, the most important and selected packages will be applied.

      The final outcomes expected from this study are:

        -  The proportion of secondary school adolescents with double burden of malnutrition who
           have received the selected double-duty interventions (DDIs).

        -  The proportion of secondary school adolescents with high dietary diversity score
           (greater than or equal to 5 food groups from ten food groups) who have received the
           selected double-duty interventions (DDIs).

        -  The proportion of secondary school adolescents with frequency of morbidity who have
           received the selected double-duty interventions (DDIs).

      Research Hypothesis of the Study

      After this study has conducted, the following proposed expected outcomes will be achieved.

        -  The double-duty interventions will be decreased the double burden of malnutrition in
           adolescents.

        -  The double-duty interventions will be increased dietary diversity score of adolescents.

        -  The double-duty interventions will decrease the frequency of morbidity of adolescents.

      Methods and Materials of the Study

      Study area, period, and setting

      This study will be conducted in Debre Berhan Regiopolitan City, North Shoa Zone, Amhara
      Region, Central Ethiopia. Debre Berhan Regiopolitan city is located 130 km away from Addis
      Ababa (the capital city of Ethiopia) and 690 km from Bahir Dar (the capital city of the
      Amhara region). It was founded by Emperor Zara Yakoob, and it is the capital city of North
      Shoa Zone of Amhara region. The city has coordinated with 9°41'N 39°32'E latitude and
      longitude, respectively. It is found at, 2840 m above sea level, which makes it the highest
      city of this size in Africa.

      Study Design

      This study will be used a six-month two-arm parallel design community-based cluster
      randomized controlled trial using clusters (kebeles) as a unit of randomization in the city.
    

Intervention name(s): Double duty interventions using nutrition behavior change communication approach
Intervention type(s): Behavioral
Intervention description(s): The packages of the double-duty interventions were modified and adapted from the 2017 WHO policy brief report and Hawkes et al., 2020. These interventions are optimized strong education and nutrition behavior change communication focused on promotion of healthy diets (adequate adolescent nutrition, dietary diversity), physical activity (doing moderate intensity physical exercise, avoiding sitting for log time), prevent undue harm from energy-dense foods (avoiding Junk processed foods, avoiding fizzy sweetened drinks, street fast foods, chips, salt, sugar, fats etc.), and regulations on marketing foods from the customer side (e.g., buying of packed foods frequently).
Other intervention name(s): Nutrition education and counselling (NEC), nutrition behavior change communication (NBCC)
Allocation: Randomized
Intervention model: Parallel Assignment
Intervention model description: A two-arm parallel cluster randomized control trial
Masking: Triple (Participant, Care Provider, Outcomes Assessor)
Primary purpose: Prevention
Keywords: Double burden of malnutrition; Double-duty interventions; malnutrition; nutrition interventions