Table 4 Description of intervention studies
Source, type, geographic coverage, study type | Target group(s) | Intervention description | Intervention category | Multisectoral approach | Nutrition-related outcome categories and results | Lessons learned |
|---|---|---|---|---|---|---|
Grant et al. (1986) [62] Published, database search Sub-national Programme evaluation | Children < 5 years | 10–15 minutes of group education for waiting mothers by trained nurses to explain growth chart | Awareness | None | Literate and numerate mothers had significantly higher mean comprehension score than those who were not but no differential effect on nutrition status of their child; 62% of mothers understood the purpose and could distinguish good vs. bad weight, 49% understood upper line, 47% understood lower line, 45% understood space in between | Clinic staff time was consumed by explaining the chart, staff availability was the largest constraint on expanding services; authors cautioned activity expansion until randomised trial is conducted |
Cheung, et al. (2003) [50] Published, database search Sub-national Case study | Households | Treatment for scurvy: 200 mg/day of vitamin C for 2 weeks for children and 1 g/day for 2 weeks for adults, including health education | Micronutrients | None | 12 of 18 suspected scurvy cases were clinically confirmed (4 in children 3–5 years); over 3 months, the scurvy rate was 6.3% (4588 cases in population of 72,835) [severe level by WHO standards]; curative treatment of vitamin C tablets showed symptom reduction | Need field-friendly methods of confirming micronutrient-deficiency diseases; need to validate standard clinical case definition and include in endemic/outbreak-prone area surveillance; need to introduce and mainstream clinical micronutrient deficiency assessment and diagnosis into common assessment tools (i.e. nutrition surveys), train survey staff to identify micronutrient-deficiency diseases |
Kim et al. (2008) [63] Published, database search Sub-national Programme evaluation | Households | Interactive electronic picture book, Afghan Family Health Book, to communicate public health messages on 17 topics: immunisation, micronutrients, WASH, diet, malaria, tuberculosis, acute respiratory infections, sexually transmitted disease, safety, first aid, mental health, female anatomy, birth spacing, breastfeeding and peripartum care | Awareness | None | Statistically significant improvements in knowledge on all health topics except female anatomy and sexually transmitted diseases; all users reported the Afghan Family Health Book to be too complicated and difficult to understand and CHW teachings were preferred | Scepticism of health education via electronic modes in areas where books are scarce and electronic devices are rare; interactive technology has potential to convey public health messages in such settings, although CHWs preferred |
Grunewald et al. (2008) [64] Gray, hand search Sub-national Programme evaluation | Household, with a focus on mothers and children | 20 FAO-executed projects; support to household food security, nutrition and livelihoods, with focus on piloting interventions and building MAIL capacity | Package of interventions | Agriculture and livelihood interventions with nutrition lens | Descriptive: lack of consistent monitoring and evaluation resulted in unmeasured indicators; those measured were mostly output indicators (e.g. number of trainings); used nutrition education booklets and posters with 9 key messages, trials of improved practices to improve household feeding practices and to test improved local IYCF and family recipes resulted in guide on improved feeding practices and recipes for Afghan children and mothers (3rd joint MAIL/MoPH publication) | Range of interventions left little time to test and accumulate sufficient data; questions remain for best target group; no thorough analysis of different models used, suitability of messages, no costs/benefits analysis; low land ownership/access to resources by women impeded project component implementation; practical livelihood support to increase production, diversify food production, food processing and conservation, and marketing should be provided with nutrition education |
Manaseki-Holland et al. (2010) [65] Published, database search Sub-national RCT | Children 0–24 months | Supplementation of 100,000 IU of vitamin D3 (cholecalciferol), along with antibiotic treatment | Micronutrients | None | No significant difference in the mean number of days to recovery between two study arms; risk of a repeat episode within 90 days of supplementation was lower in intervention vs. placebo group (58%; relative risk 0.78; 95% CI 0.64–0.94); intervention group had longer duration to a repeat episode (72 days vs. 59 days; HR 0.71; 95% CI 0.53–0.95) | Repeat episodes of pneumonia could be reduced with a single high-dose oral vitamin D3 supplementation along with antibiotic treatment |
Manaseki-Holland et al. (2012) [66] Published, database search Sub-national RCT | Children 1–11 months | Oral 100,000 IU (2.5 mg) vitamin D3 with placebo | Micronutrients | None | No significant difference between incidence of first or only pneumonia between vitamin D3 (0.145 per child-year, 95% CI 0.129–0.164) and placebo groups (0.137, 0.121–0.155) | Pneumonia incidence in infants was not reduced with quarterly doses of oral vitamin D3 supplementation |
Aluisio et al. (2013) [67] Published, database search Sub-national RCT | Children 0–24 months | 6 quarterly doses of oral vitamin D3 (cholecalciferol 100,000 IU or placebo) | Micronutrients | None | No significant difference in survival time to first diarrheal illness; incidence of diarrheal episodes were 3.43 (95% CI, 3.28–3.59) and 3.59 per child-year (95% CI, 3.44–3.76) in placebo and intervention arms, respectively | Authors do not recommend vitamin D3 supplementation to populations comparable to the one studied here given this study found no benefit for diarrheal illness prevention |
Morikawa et al. (2013) [68] Published, database search Sub-national Programme evaluation | Children <5 years | Inpatient mother–child feeding centre that accommodates children <5 years with moderate malnutrition with psychosocial bonding support, SFP with monthly growth monitoring for 6 months after discharge until child reaches 85th percentile of their weight-for-height measure, lactating mothers also given food supplements at feeding centre with their child | Prevention and treatment of malnutrition | None | Observed significant and continuous gain in both weight and height of child during 6-month follow-up after discharge from feeding centre | Inpatient feeding focusing on building strong bonds between mothers and children should be evaluated for its impact on child development and nutrition |
Munroe et al. [69] Gray, hand search National and sub-national Programme assessment (qualitative) | Households, health facility staff, policy-makers | Training on IYCF, micronutrients, health and hygiene for medical staff, CHS, CHW, health shuras, teachers, CDCs; training on family nutrition, including age-based diet requirements, food hygiene and healthy recipes, health staff trained on BF counselling and practices; nutrition education materials developed (BF, WASH, micronutrient guidelines), growth charts printed and training in growth monitoring; training on cooking sessions for complimentary feeding, growth monitoring, CMAM, community gardens, MUAC screenings; solar dehydration for food products, milk and potato processing, food processing and packaging training; nutrition material in national primary education curriculum; food-based dietary guidelines developed | Package of interventions | Agriculture interventions, non-health sector staff trained in growth monitoring, nutrition in primary school curriculum | Many programme output indicators, main nutrition indicators were MUAC-related, nutrition outcomes: GAM (MUAC <12.5 cm and/or bilateral oedema): 17.1%; MAM (MUAC 11.5–12.4 cm and no oedema): 10.3%, SAM (MUAC <11.5 cm and/or bilateral oedema): 6.8% | Interaction between agencies included an inception workshop and regular meetings but limited substantive collaboration in actual joint programming; many activities implemented in isolation by different IPs, making sustainability unlikely (i.e. study done by one IP on micronutrient deficiency not used by another IP with resultant mixed messaging about micronutrients, IPs implementing food security programmes using different models for the similar activities, etc.); where integration of nutrition and food processing did occur (guidelines developed and used by other agencies, food processing activities), activities were implemented directly by single team working together, with both nutrition and food security specialists; programme was geographically broad making it difficult to test an integrated model and measure attributable change |
Ahmed et al. (2014) [70] Published, database search Sub-national Review of CMAM programmes | Children <5 years | CMAM, regular field monitoring and supportive supervision of nutrition activities | Malnutrition prevention and treatment | None | Case fatality rate in children with SAM admitted to hospitals is around 6%; SAM: 7.2%; MAM: 139%; SAM cases: 399,312 | Constraints to implementing facility-based treatment of SAM: low coverage, lack of monitoring system, staff and space shortage, turnover of trained staff, lack of motivated staff; constraints to implementing CMAM treatment in communities: low coverage, monitoring, access to facility, lack of partnership; area for improvement: community mobilisation |
Mayhew et al. (2014) [71] Published, database search Sub-national Programme evaluation comparing participants with non-participants | Children 0–24 months | cGMP: monitor weight of children 0–24 months to identify those not gaining adequate weight, give caretakers tools to aid children in ‘catch-up’ growth and promote optimal feeding practices, and create social change by mobilising caretakers to regularly weigh children <24 months and discuss appropriate food and feeding techniques | Malnutrition prevention and treatment | None | Where cGMP was implemented, a mean WFA Z-score was 0.3 Z-scores higher than among matched non-participants living outside cGMP programme catchment areas; those with initial WFA Z-score of <−2 experienced mean increase of 0.33 (95% CI 0.29–0.38)/session attended; those with baseline WFA Z-score >0 showed decrease of 0.19 (95% CI 0.22–0.15)/session attended | Potential to contribute to improving nutrition in underweight children who enter programme at less than 9 months of age and attend 50% or more sessions; authors suggest long-term evaluation to assess sustained growth in matched pairs of children up to 5 years of age and include more extensive inquiry into food security, wealth and other potentially confounding factors |
Nasrat et al. (2014) [72] Gray, hand search Sub-national Programme assessment (qualitative) | EPHS/BPHS health facilities' clients | Nutrition component under BPHS and EPHS | Malnutrition prevention and treatment | None | Qualitative assessment of service delivery by key themes: staffing, training and capacity development (PND/PPHO understaffed, health staff not trained in nutrition services); management and support services (poor supervision and monitoring); service delivery (most facilities not offering complete nutrition service package, especially CHCs and BHCs) | Nutrition component is under-staffed and under resourced, optimal nutrition services not delivered through BPHS and EPHS |
World Bank Group (2014) [73] Gray, hand search Sub-national Programme evaluation | Households, with focus on women and children 0-23 months | Nutrition and hygiene awareness pilot, part of Afghanistan Safety Nets Project (unconditional cash transfer), added as a soft conditionality to raise awareness: 2 educational sessions (beginning and end) with a small evaluation at midline to improve delivery between the two sessions; households received food packets and soap cakes; messages on handwashing at key points, IYCF (EBF/CF). | Awareness | Nutrition education with safety net programme | Participants appeared to understand importance of breastfeeding, but not when and how complementary food other than breastmilk should be introduced, appropriate complementary feeding was the most frequently misunderstood survey question; participants misunderstood messages on handwashing before key actions compared to after, especially importance of handwashing before feeding infants and children | No behaviour change data presented; more than two points of contact needed to ensure message retention; more focus on tools for targeting husbands and mothers-in-law due to their role as key influencers |
Akseer et al. (2016) [74] Published, database search National and regional Observational study | Children < 5 years | Modelling of interventions with the Lives Saved Tool (LiST): EIBF (within 1 hour), 3 doses of DPT vaccine, measles vaccination, full immunisation of children, vitamin A supplementation, ORT and continued feeding for children with diarrhoea | Modelling package of interventions | None | EIBF: 53.6%, Q1: 52.1%; Q5: 54.3%; Vitamin A in past 6 months: 50.5%, Q1: 43.7%, Q5: 49.1%; Full immunisation: 17.6%, Q1: 13.2%, Q5: 19.4%; ORT: 45.8%, Q1: 47%, Q5: 54.3% | Significant variation in coverage and inequalities across various regions; composite intervention coverage lowest in most remote and isolated regions (Northern and Central Highlands) and highest in regions and provinces with major urban hubs (Nangarhar, Herat and Kabul) |
JS Consultancy (2016) [75] Gray, hand search Sub-national Programme evaluation (qualitative) | Women who had a child ≤6 months | Brochures on best practices for newborn were provided to new parents with messages on EIBF, EBF for first 6 months, delayed bathing and recognising newborn complications for early care seeking | Awareness | None | No significant differences between baseline and endline in the proportion of women reporting any breastfeeding (96% vs. 94%) and EIBF; most women reported doing both | Focus on food consumption increased during pregnancy but not micronutrients, no details on ANC counselling on nutrition |
Higgins-Steele et al. (2017) [76] Published, database search National Observational study | Children < 5 years | Using LiST tool: EBF <1 month, EBF 1–5 months, any BF 6–11 months, any BF 12–23 months, CF education only, CF supplementation and education, vitamin A supplementation, WASH, handwashing with soap, hygienic disposal of children's stools, pentavalent vaccine, pneumococcal vaccine, rotavirus vaccine, measles vaccine, injectable antibiotics, ORS, antibiotics for dysentery, zinc for diarrhoea, oral antibiotics for case management of pneumonia, therapeutic feeding for severe wasting, MAM treatment | Modelling package of interventions | WASH interventions included in the modelling | 71% reduction in child deaths due to diarrhoea and pneumonia between 2016 and 2020 (for diarrhoea, a 85% reduction; for pneumonia, a 63% reduction) compared to 47% reduction in the moderate scenario (for diarrhoea, a 35% reduction; for pneumonia, a 63% reduction) | Better modelling tools are needed to adequately capture impact of nutrition on childhood mortality, investment is needed to strengthen CHW cadre, expand coverage of immunisations |
Venkataramani et al. (2017) [77] Published, database search National Observational study | Children < 5 years | IMCI screening | Malnutrition prevention and treatment | None | Primary outcome was an assessment index measuring the healthcare provider’s adherence to selected IMCI screening tasks; visits with any IMCI-related complaint were associated with higher assessment indices than visits with no IMCI-related complaints | Presenting complaints are an important factor in providers adhering to the IMCI assessment algorithm; children who present with only non-IMCI complaints may be at risk for not being screened for critical IMCI conditions |
Mansoor et al. (2017) [78] Published, hand search National Programme evaluation | Children < 5 years | Introduction and scale-up of IMCI at primary healthcare facilities | Malnutrition prevention and treatment | None | On average, 5.4 of 10 main assessment tasks were performed during paediatric examination; more than half were assessed for three main symptoms of cough, diarrhoea and fever; 28% (n = 30) of children <2 years of age were assessed for feeding practices; 34% (n = 60) were weighed and checked against growth chart | IMCI training not fully scaled to cover all health workers, healthcare providers trained on IMCI more likely than untrained providers to conduct a systematic assessment of a child’s condition |
Pedersen S, et al. (2016) Gray, hand search Sub-national Programme evaluation (qualitative) | Children <5 years, mothers | Package of community and facility-based interventions that provide preventive and curative health and nutrition services; established and trained FHAGs, CHWs and HF staff on IYCF messages; IYCF counselling; Positive Deviance Hearth; cGMP; community WASH groups; VIP latrines; dietary diversity awareness; home garden support and training for women, poultry livelihood training and distribution; MNP distribution; strengthen IPD/OPD SAM; CMAM/IYCF training for nutrition nurses; CME/CNE nutrition SOP training | Package of interventions | Agriculture interventions (home gardens and chickens for women) | Of the 18 MUNCH interventions, 10 had targets listed in the annual work plans; targets were met for Timed and Targeted Counselling training and exceeded for latrine building, establishing IPD/OPD SAM Centres, distribution of MNP, distribution of chickens, and establishing home gardens; three interventions, gender equality training, mHealth (mobile health) training, and IYCF message training, missed their targets. Positive Deviance Hearth achieved 50% of its target number of children achieving minimum weight | FHAGs, Positive Deviance Hearth and WASH groups were particularly important to establishing good practices in the community; these interventions demonstrate value of community driven action |
Global Alliance for Improved Nutrition (2017) Gray, hand search National Evaluation | Households | National salt iodisation and fortification of wheat flour and oil | Micronutrients | Micronutrient fortification in foods | Awareness of fortification was low: 22% of households reported hearing about fortified foods, 35% in Kabul compared to 33% in other urban areas and 20% in rural areas; level of fortification was inconsistent with national standards: 2% of salt brands, 4% of oil brands and 10% of wheat flour brands were fortified within the standard range; 71% of salt brands and 51% of wheat flour brands were partially fortified but only 35% of oil brands were fortified at all | High potential for impact from large-scale fortification of salt and oil; potential for wheat flour is lower; further exploration needed to assess feasibility of targeting small-scale producers; for all food vehicles, monitoring, regulation and enforcement are critical to improve the level of fortification, for both domestic and imported products; future research should assess nutrient contribution from fortified foods and total intake of nutrients from all dietary sources to see if dietary nutrient gap is filled through fortification efforts |