Morbidity Evaluation of an Innovative Feeding Toolkit to Improve Complementary Feeding in Malawi
Authors: Ko Jasmine , Faerber Emily , Weiss Jennifer , Girard Amy Webb 
Published: November 2023

BackgroundChildhood malnutrition is associated with increased morbidity due to infectious diseases.ObjectiveA cluster randomized controlled cohort study was conducted to test whether an innovative feeding toolkit improves complementary feeding practices and infant growth. We additionally assessed the impacts of the intervention on morbidity.Methods1,344 households in 3 traditional authorities in Mchinji District, Malawi with at least one child aged 6 to 17 months and whose caregiver participated in community women's groups were enrolled at baseline. In Oct/Nov 2015, community groups were randomized to either the intervention or control, with households in the intervention eligible to receive a toolkit consisting of a bowl with demarcations on age‐appropriate meal volumes; a slotted spoon designed to promote optimal food consistency; and nutrition education. Caregivers in the control groups received nutrition education only. 963 households who participated at baseline and 67 additional households were followed up in Jun/Jul 2016 for a mixed methods endline evaluation including a household survey and focus group discussions. Logistic regression models, accounting for a clustering effect, were fitted to determine the impact of receiving the toolkit on morbidity outcomes.ResultsAt endline, the mean age of surveyed children (n=1030) was 21.4±3.37 months; 48% were male. Receipt of a toolkit was not associated with the odds of any reported illness in the previous 2 weeks (OR: 0.92, 95% CI: 0.66, 1.30). However, receipt of a toolkit appears to be significantly associated with an increased odds of diarrhea (OR: 1.65, 95% CI: 1.10, 2.47) in the previous 2 weeks. Qualitative interviews with caregivers at endline indicated that food insecurity was a major barrier to utilization of the intervention toolkit and quantitative analyses revealed a significant interaction between receiving a toolkit and household food security on any illness in the previous 2 weeks (p=0.06). In stratified analyses, while the direction of the intervention effect differed between the two groups, receipt of a toolkit was not statistically significantly associated with the odds of any illness among food secure / mildly food insecure households (OR: 1.49, 95% CI: 0.81, 2.75) or food insecure households (OR: 0.76, 95% CI: 0.52, 1.13). Those who both received a toolkit and were food secure / mildly food insecure had significantly reduced odds of any illness, compared to those who did not receive a toolkit and who were moderately / severely food insecure (OR: 0.59, 95% CI: 0.36, 0.97).ConclusionA feeding toolkit that cues appropriate complementary feeding practices may reduce all‐cause morbidity, but effects appear to be modified by food security status. Larger sample sizes may be needed to further explore these relationships. Increased odds of diarrhea may be attributable to hygiene‐related issues and merits further investigation.Support or Funding InformationFunding and support for this research was provided by Concern Worldwide; Malawi Department of Nutrition, HIV and AIDS; the World Bank; Emory Global Health Institute; Laney Graduate School, Emory University; and the National Institute of Diabetes and Digestive and Kidney Disease of the National Institutes of Health under award number T32DK007734.