Dietary and water, sanitation, and hygiene patterns in children 6–23 months of age participating in a feeding and behavioral change communications program in rural Malawi
Authors: Ruel‐Bergeron Julie C , Hurley Kristen , Monclus Assumpta Bou , Kang Yunhee , Wu Lee Shu Fune , Mitra Maithilee , Phuka John , Klemm Rolf , West Keith , Christian Parul 
Published: November 2023

BackgroundSince January 2014, the Government of Malawi has been implementing a nutrition program that delivers a small‐quantity lipid‐based nutrient supplement (LNS) with a social behavior change communication (SBCC) package of infant and young child feeding (IYCF) and water, sanitation, and hygiene (WASH) messages.ObjectiveTo assess mid‐program (interim) IYCF and WASH outcomes among children 6–23 months of age in the program district in Malawi, as compared to children of the same age in a neighboring comparison district that receives only the SBCC component.MethodsAn interim assessment was conducted after 1 year of program implementation and included 2,120 children aged 6–23 months (n=912 and n=1,208 in the program and comparison districts, respectively). A program exposure score (range 0–5: 1 point per tertile of participation in SQ‐LNS component in program district, and 1 point each for maternal report of exposure to one‐on‐one and group counseling, and mass media messaging in both districts), which was assessed against the following interim IYCF and WASH outcomes: dietary diversity score (DDS), minimum dietary diversity (MDD), minimum meal frequency (MMF), minimum acceptable diet (MAD), hand washing at 5 critical time points, latrine ownership, use of improved drinking water, water treatment, giving treated water for children to drink, and presence of feces in/around the household compound. Multiple linear and logistic regressions models were used for continuous and binary outcomes, respectively, accounting for potential confounders (wealth, maternal education, child age, child sex, and household food insecurity as appropriate), as well as village level clustering.ResultsProgram exposure scores (Mean ±SD) in the program and control districts were 3.11±1.07 and 1.02±0.62, respectively. Program exposure was associated with increased hand washing (with soap) before cooking (OR=1.14, p<0.05), but paradoxically, not after cleaning feces (OR=0.91, p<0.05) or after using the toilet (OR=0.89, p<0.05). Program children were less likely to report diets that met the MDD (OR=0.83, p<0.01), MMF (OR=0.91, p<0.05) and MAD (OR=0.83, p<0.01). However, the relation between level of program exposure and DDS varied by household food security status; children whose program exposure score was 3 and living in a household with mild food insecurity saw the greatest benefit on DDS (β=1.95, p<0.01) as compared to children with low participation in food secure households (F‐test p<0.01). The highest levels of program exposure (score of 5) did not have a significant association with DDS, regardless of food security status.ConclusionAn interim assessment of level of program exposure revealed a threshold at which program exposure is likely to be most beneficial for dietary diversity, especially among food insecure households.Support or Funding InformationFunded by the Children's Investment Fund Foundation (CIFF).

Association between program exposure on intermediate IYCF and WASH practices

%
OR (95%. CI)
p‐value

WASH Indicators

Feces in/around HH compounda
34.80
0.98 (0.88, 1.09)
0.671

Latrine ownershipa
86.01
1.09 (0.98, 1.22)
0.118

Use of improved water sourceb
81.56
1.19 (0.99, 1.44)
0.069

Treats drinking waterb
36.19
0.97 (0.88, 1.06)
0.475

Gives child treated drinking watera
74.43
0.84 (0.75, 0.94)
0.003

Washes hands with soap before cookingb
21.28
1.14 (1.01, 1.28)
0.031

Washes hands with soap before feedingb
5.42
0.89 (0.75, 1.06)
0.202

Washed hands with soap after cleaning fecesb
36.91
0.91 (0.82, 1.00)
0.047

Washes hands with soap after using toiletb
45.45
0.89 (0.81, 0.98)
0.019

Mean
β ± SE
p‐value

Hand washing score (0–5)b
1.57
−0.02 (−0.08−0.04)
0.475

IYCF Indicators

Dietary diversity score (DDS) (0–7)d
2.56
−0.04 (−0.89–0.002)
0.061

%
OR (95% CI)
p‐value

MDDd
18.23
0.83 (0.74, 0.92)
0.001

MMFd
74.78
0.91 (0.84, 1.00)
0.047

MADd
16.17
0.83 (0.74, 0.93)
0.001

Adjusted for wealth and maternal education;
Adjusted for wealth, distance to water source, and mom's education;
c Adjusted for wealth, mom's education, child age (months), and child sex;
Adjusted for wealth, mom's education, child age (months), child sex, and household food insecurity.