Peer Groups to Improve Infant Feeding Practices and Child Growth in Post-emergency Settlements in Uganda
Condition: Infant Malnutrition
MeSH terms: Malnutrition; Infant Nutrition Disorders; Emergencies
Study type: Interventional

Summary: 
      The goal of this randomized trial was to examine whether a peer-to-peer integrated
      intervention using Care Groups combining nutrition education and social support will improve
      infant growth and complementary feeding practices among refugees in the West-Nile region in
      Uganda. The aims of the study were to 1) determine the relationship of the intervention using
      the Care Group model on complementary feeding of infants, and 2) investigate the effects of a
      peer-led integrated nutrition education intervention using the Care Group model on growth
      among infants of refugees in Uganda.

      Pregnant mothers (390) in their 3rd trimester were enrolled in a peer-led nutrition education
      intervention using the Care Group model. One treatment arm had moms only in the Care Groups
      while the other treatment arm had both moms and dads in the groups. Each study arm had a
      total of 10 Care Groups with 10-20 participants each. The control arm equally had 10 groups,
      however, did not receive the intervention. Each of the treatment arms participated in a
      biweekly integrated nutrition training hypothesized to effect behavioral change in infant
      feeding practices. The biweekly training started in March 2022 and ended in December 2022
      with data collection at four-time points during the study (baseline, midline-I, II, and
      endline). Infant complementary feeding was evaluated using the World Health Organization &
      UNICEF guidelines. Infant growth was assessed using length-for-age z-scores, weight-for-age
      z-scores and weight-for-length z-scores. The Medical Outcomes Study (MOS) Social Support
      Index was used as a proxy to measure maternal social support. Effects of Care Group
      intervention on infant complementary feeding and growth were tested by study arm compared to
      the control arm.
    

Detailed description: 
      Brief introduction:

      Low-and middle-income countries (LMICs) are "home" to most of the world's refugees, the
      majority of whom are women and children. Refugee children are vulnerable to undernutrition
      and poor health, and humanitarian agencies have highlighted child undernutrition as a key
      area for intervention during refugee situations. Complementary feeding of infants in refugee
      settlements remains inadequate; however, there is limited evidence on how to address these
      nutritional challenges in refugee settlements. In 2020, I conducted a year-long
      community-based randomized control trial among post-emergency settlements in the West Nile
      region in Uganda to examine whether an integrated nutrition education intervention delivered
      through Care Groups would improve infant feeding practices and growth in the post-emergency
      settlements in Uganda. The findings in this study may be used to design nutrition-sensitive
      programs and also inform policies targeting complementary feeding practices within
      post-emergency settlements in Uganda.

      Study area:

      The Adjumani district had been randomly selected among six districts and one city hosting
      refugees in the West Nile region. Initially, three settlements in the Adjumani district were
      randomly selected and assigned to the three arms of the study. Ayilo-I settlement was
      assigned as a Moms-only treatment arm, Pagirinya settlement was the Moms & Dads treatment arm
      while Nyumanzi settlement was the Control arm. During the recruitment of the participants,
      some fathers in the settlement (Pagirinya) assigned to the Moms & Dads treatment could not
      commit to participating in a year-long study because they had to move away from the
      settlement for jobs back to Juba, the capital of Sudan or nearby towns with more employment
      opportunities. Because of the limited number of participants in the Moms & Dads arm, a second
      randomization was done excluding the already selected settlements. Ayilo II was then selected
      as the other settlement to identify respondents for the Moms & Dads treatment arm. These
      settlements were at least six kilometers apart to reduce the possibility of spillover effects
      of the intervention. The village health team (VHTs) and health center midwife assistants
      supported the identification of pregnant mothers to be included in the study.

      Sample size:

      Prompt introduction of solid and semi-solid foods to infants was used as the primary outcome
      to determine the sample size because of its reliability as an indicator of infant and young
      child feeding practices. A sample size of 317 mothers was desired for strong power, based on
      calculations using GPower 3.1 software, with a type I error of 0.05, a power of 0.90, and an
      effect size of 0.2 to detect differences in the proportions of infants introduced to
      complementary foods at 6-8 months among the 3 study arms. A 23 percent loss during follow-up
      was estimated; thus, 390 women (15-49 years of age) in their third trimester of pregnancy
      were willing to participate. These women were enrolled before baseline data collection.
      Husbands were eligible to participate with their wives in the Moms & Dads treatment arm. A
      total of 321 mother-infant dyads completed the study.

      Purposive sampling was used to identify pregnant women in their 3rd-trimester to be included
      in the study. VHTs and a midwife assistant from each settlement were contacted to support the
      respondent identification process due to their community roles in promoting health among
      expectant mothers. Identified pregnant women were crossmatched with an integrated maternity
      register from the health facility. Verification of pregnancy term was done with the help of
      the midwife assistant, VHT, and researcher by validating records in the antenatal card or
      maternity records book. Each of the chosen settlements formed the household sampling frame
      for one arm of the study; that is, each settlement had either: 1) Moms-only, 2) Moms & Dads
      combined, or 3) Control arm. The participants in the study were followed up from recruitment
      in January 2020 to the end of the study in December 2020.

      Study Intervention:

      A peer-led integrated nutrition education training program using the Care Group model
      developed by the USAID TOPS program comprised the intervention. We hypothesized that
      participants in the Care Group intervention would have better peer support and would have
      improved infant complementary feeding and growth compared to the participants in the control
      arm. For the intervention arms, topics trained in the peer support groups included 1) group
      dynamics and social support, 2) optimal breastfeeding and complementary feeding practices, 3)
      adequate basic hygiene, 4) child growth and development, and 5) fathers' involvement. The
      training messages were adopted and modified from the community health extension workers
      (CHEWs) training handbook and the United Nations Children Emergency Fund (UNICEF) infant and
      young feeding counseling cards for community workers. Selected images were included in each
      module for illustration adopted from the UNICEF-IYCF counseling cards for community workers.

      Intervention groups:

      In this study, Moms-only and Moms & Dads arms comprised the treatment arms also referred to
      as the intervention arms. The Control arm was the third study arm but did not receive the
      intervention. Each study arm comprised 10 groups with 10 - 20 members per group. For the
      study arms, volunteer leaders were selected within each group by the members. These leaders
      were referred to as peer group leaders. For the intervention arms, the peer group leaders
      were trained for five days using the same training tool that was to be used during the Care
      Group meetings. The peer group leaders were trained by identified village health team (VHTs)
      together with a nutrition and health educator from the Adjumani district. Only one refresher
      training for the peer group leaders was done during the entire study period even though at
      least two refresher trainings had been planned. The failure to conduct additional refresher
      training was due to measures undertaken to observe COVID-19 safety operating procedures
      (SoPs). Nevertheless, monthly feedback meetings were held for the peer group leaders with the
      VHTs to harmonize group meeting plans and address any challenges. These monthly meetings were
      also attended by the researcher. Each of the peer group leaders facilitated integrated
      nutrition training modules on a biweekly basis to the 10 to 20 group members identified in a
      Care Group to effect behavioral change. The group members were also encouraged to visit each
      other's homes as part of peer follow-up, however, caution to COVID-19 SoPs was emphasized.

      Standard of care/ Control arm:

      In this study, the Control arm did not receive the intervention. The Control arm comprised a
      standard of care that was expected to involve VHTs doing their routine work in the community
      supporting households concerning nutrition and health information for better maternal and
      child health. The GoU recommends having at least two VHTs in a village, which is between 50
      and 70 households. These VHTs report directly to the nearest government health facility.
      Additionally, the VHTs are expected to promote government health programs and urge community
      members to access health-related services from government facilities.

      Data Collection:

      The structured questionnaire used for this study was adapted from the Demographic and Health
      Surveys and UNHCR standardized expanded nutrition surveys (SENS) guidelines. These two
      questionnaires have been widely accepted for sociodemographic, health, and nutrition data
      collection and related information for nationally representative samples and humanitarian
      populations. Additional questions to assess maternal social support were adopted from the
      medical outcomes study (MOS) social support scale. The final questionnaire was translated
      into Arabic, Dinka, and Madi languages which are widely spoken by the South Sudanese in the
      refugee settlements in Uganda. The questionnaires were then uploaded onto electronic tablets
      (Lenovo Tab P11) using the Qualtrics software (Offline version). The collected data with the
      electronic tablets were uploaded to Qualtrics cloud storage at the end of each data
      collection day. Only the principal investigator and research collaborators had access to the
      data as part of maintaining respondent data safety.

      Four enumerators with a minimum qualification of an associate degree in nutritional science,
      social sciences, or related fields were recruited and trained on the questionnaire. Each
      enumerator was proficient in English and Arabic and one of the local languages (Madi, Nuer,
      or Dinka). A total of 10 households with women pregnant in their 3rd trimester were used to
      pretest the questionnaire in the Boroli refugee settlement. The Boroli refugee settlement
      where the pretesting was done was not among the settlements that were selected for the
      year-long study. The researcher was able to make minor revisions and adjustments mostly
      regarding the flow of questions in the Qualtrics software. Data collectors/enumerators were
      blinded from the study arm assignment. The collection of data/information from a single
      respondent was completed within 1 hour and 30 minutes. The data collection time points for
      this study were baseline (January), Midline-I (June), Midline-II (October), and Endline
      (December). At each data collection period, the participants were provided with a 1 kg bar of
      washing soap, 200 mL of vitamin A fortified cooking oil, and half a kilo each of iodized salt
      and sugar, all worth about 7,600 Ugx (1.5 USD) as compensation for participation in the
      study.

      Ethical Considerations:

      This study was approved by the Institutional Review Boards of the Uganda National Council of
      Science and Technology (SS 5038), Makerere University School of Health Science Research and
      Ethics Committee (SHSREC REF:2019-020), and Oklahoma State University (HS-19-2). Additional
      permission was acquired from the Office of the Prime Minister (OPM) Uganda (OPM/R/107).
      Informed consent was obtained from all respondents at recruitment for participation in the
      study, and before data collection during the study.
    

Intervention name(s): Peer-led integrated nutrition education intervention delivered through Care Groups
Intervention type(s): Behavioral
Intervention description(s): The intervention comprised a peer-led integrated nutrition education training using the Care Group model developed by the TOPS program [13]. In the treatment arms, topics trained in the peer support groups included 1) group dynamics and social support, 2) infant feeding 3) adequate basic hygiene, 4) child growth and development, and 5) fathers' involvement. The training modules were adopted and modified from the community health extension workers (CHEWs) handbook [14] and the UNICEF IYCF counseling cards for community workers [15, 16]. Over the study, the intervention participants also engaged in cooking demonstrations targeting infant complementary foods preparation and backyard kitchen gardening.
Allocation: Randomized
Intervention model: Parallel Assignment
Intervention model description: The intervention in Moms-only arm was run concurrently with a similar intervention in the Moms and Dads treatment arm. At the same time, the Control arm did not receive any intervention. Data were collected from all study arms at the same time during the study in order to compare the effect of the intervention in the treatment arms against the control.
Masking: Double (Participant, Outcomes Assessor)
Primary purpose: Other
Keywords: Infant complementary feeding; Refugees; Post-emergency settlements; Infant growth; Uganda; Maternal social support