Large-Scale Behavior-Change Initiative for Infant and Young Child Feeding Advanced Language and Motor Development in a Cluster-Randomized Program Evaluation in Bangladesh

"[T]he findings reinforce efforts to develop and evaluate integrated nutritional and developmental interventions...that efficiently and effectively support parents and other caregivers to provide optimal, holistic care for their infants and young children, which will lead to physical, cognitive, and socio-emotional development."

Undernutrition remains a substantial challenge in Bangladesh. In addition, disadvantaged young children have low scores on measures of early childhood development. Can programmes that are focused on improving nutrition through behaviour change contribute to child development, even without specific early childhood development interventions? This question is at the heart of a study examining whether an intensive intervention package that was aimed at improving infant and young child feeding (IYCF) through the Alive & Thrive (A&T) initiative in Bangladesh also advanced language and gross motor development, and whether advancements in language and gross motor development were explained through improved complementary feeding.

A&T delivered the large-scale intensive package in 50 rural subdistricts in Bangladesh through the existing health programme of BRAC (for more information, see Related Summaries, below). The package went beyond typical nutrition education interventions by providing intensive counseling delivered by highly trained and closely supervised frontline workers who received incentives for quality of performance. The new nutrition workers called Pushti Kormi together with the regular community health workers called Shasthya Sebika conducted multiple household visits with pregnant women and mothers of children ≤2 y of age to counsel them on IYCF messages, coach mothers as they tried out the practices (e.g., responsive feeding), and engage other family members to support the behaviours. The counseling intervention was delivered in the context of a national mass media campaign and social mobilisation at the community level, both focused on strengthening the household environment for optimal IYCF. Parents were exposed to the mass media by watching the national broadcast of 7 television spots. In intensive areas that had low electricity and limited access to television, supplemental activities were conducted to air the television spots and other IYCF films produced by the project through local video screenings.

The cluster-randomised design compared 2 intervention packages: intensive interpersonal counseling on IYCF, mass media campaign, and community mobilisation (intensive) compared with usual nutrition counseling and mass media campaign (nonintensive). Twenty subdistricts were randomly assigned to receive either the intensive or the nonintensive intervention. Household surveys were conducted at baseline (2010) and at endline (2014) in the same communities (n = ∼4,000 children aged 0-47.9 mo for each round). Child development was measured by asking mothers if their child had reached each of multiple milestones. Linear regression accounting for clustering was used to derive difference-in-differences (DID) impact estimates, and path analysis was used to examine developmental advancement through indicators of improved IYCF and other factors.

The DID in language development between intensive and nonintensive groups was 1.05 milestones (P = 0.001) among children aged 6-23.9 months and 0.76 milestones (P = 0.038) among children aged 24-47.9 months. For gross motor development, the DID was 0.85 milestones (P = 0.035) among children aged 6-23.9 months. The differences observed corresponded to age- and sex-adjusted effect sizes of 0.35 for language and 0.23 for gross motor development. Developmental advancement at 6-23.9 months was partially explained through improved minimum dietary diversity and the consumption of iron-rich food.

According to the researchers, the path from the intensive intervention to advanced development was partially explained through improved complementary feeding and could have resulted from both biological (i.e., nutritional) and behavioural (i.e., caregiving) mechanisms. Further research may be helpful in understanding and increasing the potential of these mechanisms.

In conclusion, the intensive IYCF intervention package had a significant differential impact on language and gross motor development in comparison to the nonintensive intervention package. "This study shows that the documented impacts go beyond IYCF on 2 relevant developmental outcomes for young children, adding to the evidence for investments in large-scale, high-quality interventions to support IYCF."