Appropriate feeding practices are of fundamental importance for the survival, growth, development, health, and nutrition of infants and children. Considerable efforts have been made in recent years to promote breastfeeding. However, at the time of weaning, many young children do not receive adequate feeding. This can result in undernutrition, a major problem in many countries. More than 20% of children under the age of 5 worldwide are undernourished – whether stunted, wasted, or underweight. Undernutrition contributes to about one-third of the approximately nine million deaths each year among children under the age of 5 in developing countries 1. Furthermore, it increases the severity and the risk of dying from common childhood diseases 2.
The decrease in infant and child mortality over the last decade in Egypt has not been paralleled by an equivalent improvement in nutritional status, and there are even reports that nutritional status has deteriorated. The Egypt Demographic and Health Survey 2008 reported that 29% of children under the age of 5 had stunting and 14% had severe stunting. Stunting, which reflects chronic malnutrition, was high among children at 2 years of age, affecting 41% of the children. Undernutrition was attributed to a combination of poor complementary feeding and high rates of morbidity because of diarrhea and other childhood infections 3.
Decisions on how to feed young children are influenced by family beliefs, community practices, advertising by food manufacturers, and information from health workers. Health workers often fail to discuss with families how best to feed their young children because of their lack of specific knowledge and counseling skills. Hence, there is a need to train health workers who are in contact with caregivers of young children to provide them with the knowledge and the skills to support adequate feeding. These health workers will then be able to provide caregivers with accurate information and counseling 4.
The WHO complementary feeding counseling (CFC) course was formulated to improve feeding practices of children 6–24 months of age by ensuring that sound and culture-specific nutrition counseling is taught to health workers. The 3-day course aims to enable health workers to correctly assess nutritional status and feeding problems, and provide appropriate complementary feeding recommendations. It is expected that consultations will result in improved caretaker knowledge and behavior. As a result, the child’s intake of energy and nutrients should improve, with a positive impact on their nutritional status 5.
There are a number of limiting factors that may interfere with the success of nutritional counseling, such as the intensity of the intervention, timing, the adequacy of the recommendations, the existence of external constraints to the adoption of the recommendations such as low food availability, and the possibility of replacement of the current diet with the recommended foods. The objectives of the study were to test the effectiveness of the CFC course in improving primary healthcare center (PHC) physicians’ nutrition counseling knowledge and skills, to examine how these physicians’ recommendations (or advice) would assist in improving maternal knowledge and feeding practices, and, finally, how this chain of improvements would affect child nutrition and growth under field conditions.
Participants and methods
Study design and participants
The study was a clustered single-blinded randomized-controlled trial, with random allocation of 20 physicians from PHC centers to receive the CFC training course and 20 physicians from matched centers as a control group.
The 40 health centers, which comprise all PHCs in Ismailia District, were divided into matched pairs according to their location, either in rural or urban areas, and integrated management of childhood illness (IMCI) training of the selected physicians. Seventy percent of the physicians included received in-service training of IMCI course. One center from each pair was selected randomly for the intervention group by flipping a coin and the other center was assigned to the control group. In addition, two groups, each comprising 240 mother–child pairs, were included in the study in the intervention and control groups. They were followed up for 180 days. All observers, who were trained high school female graduates from the Ismailia governorate, were blinded to the intervention or control status of the participants as well as the study objectives.
Adaptation of the CFC training program and training of master trainers
The training material of the CFC course was translated into the local Arabic language and adapted to suit the local context guided by the WHO Adaptation Guide. The course was piloted before field application 5. The training of five master trainers was conducted by a team composed of three WHO experts over a period of 3 days. Furthermore, special ‘Child Card’ was translated into the Arabic language, with complementary feeding instructions 5.
Training of physicians
The training program was carried out in the Fever Hospital of Ismailia city by the five master trainers. It lasted for 3 days and was delivered to 20 PHC physicians. Special emphasis was given to the development of knowledge and counseling skills on complementary feeding. The training course was composed of both theoretical and practical sessions 5. The master trainers conducted follow-up visits to each of the 20 PHC physicians who received the CFC training course. The visiting team observed feeding counseling and provided feedback to the physicians, aiming to improve their performance.
Training of field workers
Ten field workers were recruited to conduct the home-visiting program to the enrolled families. They were trained high school female graduates from the Ismailia governorate. A training program was conducted for 3 days by the study team from the Suez Canal Faculty of Medicine and MOHP to train the health workers on collecting information from the mothers using special questionnaire forms, and on taking anthropometric measurements of the study children. Then, practical training was conducted in a PHC in Ismailia city for 1 week.
Counseling program and filed work
On the basis of the adaptation of the CFC program, a ‘Child’s Card’ was developed in the local Arabic language. It was explained and handed by the CFC-trained physician to the caregivers of the mothers included in the study as part of the intervention as it assists the physicians in counseling process.
All mothers–child pairs recruited were followed up within 2 weeks, 90, and 180 days after receiving counseling on feeding.
They included healthcare providers’ knowledge of nutrition counseling and practice (counseling skills); maternal knowledge of basic nutrition-counseling recommendations, maternal compliance with the recommended feeding practice; child dietary intake; and gains in weight and length.
- Healthcare providers’ counseling skills and knowledge: three consultations in both groups were observed by the master trainers using a structured form that covered key counseling behaviors 5, and took place within 1 month after the CFC training course.
- Maternal knowledge and feeding practice: three home visits took place within 2 weeks, 90, and 180 days after inclusion in the study. Maternal recall of the complementary feeding recommendations and the feeding practices of their children were assessed using a questionnaire during the home visits 5.
- Child growth: the children were weighed using Salter spring scales (George Salter & Co., Bilston) (with an accuracy of 100 g), and their supine length was measured to the nearest centimetre using AHRTAG baby length measurers, London, UK 6.
The data from the different forms were entered using EPIINFO version 6.04 (EPI6) (Division of Surveillance and Epidemiology; Centers for Disease Control and Prevention, Atlanta, Georgia, USA) and checked for range and consistency. Data analysis was carried out using STATA version 7 (STATA Corp LP, College Station, Texas, USA). The intervention and control groups were compared in terms of baseline indicators including socioeconomic variables and nutritional conditions. Tests used included odds ratio (confidence interval), χ2, and t-test. Probability values (P≤0.05) were considered statistically significant. The significance levels were adjusted using robust confidence intervals to control for the cluster randomized design 7. The two groups were compared in terms of the outcome measures described above. Furthermore, children’s weight and length gains were measured in the 90-day and 180-day follow-up visits after recruitment. The National Center for Health Statistics reference was used for comparison of growth gain over time 8.
The study complied with the International Ethical Guidelines for Biomedical Research involving Human Subjects 9. Children in the control group continued to receive routine nutrition advice. Anthropometric research involves a ‘minimal’ risk (i.e. risk not greater than that attached to routine medical examination).
The Research and Ethics Committees of the Faculty of Medicine, Suez Canal University, and WHO cleared and approved the study protocol. Informed consent was obtained from the health workers and from the parents of children enrolled in the study. This was done after a clear description was provided of the study objectives of the procedures to which the child would be subjected, and only after ascertaining that the parents had adequately understood this information. Health workers, mothers, and children were identified by a serial number and the information at the individual level was kept strictly confidential.
Recruited children and families of the intervention and control groups were comparable in their baseline characteristics (Table 1). No child was lost to follow-up in the first round of home visits; 14 children were lost to follow-up in the second round of home visits (2.9%), seven from each group. Eleven children were lost to follow-up in the third round of home visits (2.3%), five from the intervention group and six from the control group (Fig. 1). The total loss to follow-up rate was less than 5% and cannot accordingly be considered a threat to the validity and power of the study.
Physicians’ counseling skills
There was a statistically significant difference in communications and counseling skills between the trained and untrained physicians. Trained physicians performed significantly better than untrained physicians in their communication skills – such as using simple understandable language, checking understanding of the mothers, and providing practical help to them (Table 2). Trained physicians provided significantly better counseling recommendations on complementary feeding such as the proper number and amount of feeds, and the contents of the child’s meals. Both physicians’ groups provided equally adequate breast feeding counseling (Table 3).
Maternal recall and compliance with feeding recommendations
During the home interviews conducted within 2 weeks after consultation, 82.5% of the mothers of the intervention group and 62.9% of the control group recalled receiving nutritional advice from counseling physicians. In the second home visit, these decreased to 73 and 59.7%, respectively. The same observation was made in the third home visit, 180 days after the initial counseling, as only 46.6% of the intervention group and 59.1% of the control group recalled receiving nutritional counseling. Furthermore, there was a significant decrease in the recall of the specific nutritional advice by both groups, 90 and 180 days after initial counseling, which showed no significant difference between the intervention and the control groups (Table 4).
During the first home visit, more mothers in the intervention group tended to report giving foods of animal origin and to encourage the child to eat compared with the control group. These differences were statistically significant in the first home visit; however, they decreased by the third home visit as the children became older. It is noteworthy that the proportion of mothers who reported feeding practices in both groups by the third home visit was equally high in the studied aspects such as providing the proper amount and content of food (Table 5).
The mean weight gain 6 months after recruitment was greater in the intervention group compared with the control group (0.96 vs. 0.78 kg; P=0.038). In the age subgroups, the difference in weight gain was statistically significant only among children who were 6–9 months of age at the time of recruitment (1.09 vs. 0.8 kg, respectively; P=0.02). There was no overall difference in length gain between the two study groups. However, children in the intervention group who were 12–18 months of age at the time of recruitment had significantly less faltering in length gain compared with the control group as was apparent in the height/age Z-score (0.23 vs. 0.04; P=0.004) (Table 6).
The results of the present study showed that CFC training improved physicians’ performance, mothers’ feeding knowledge and reported practices, and growth of children. The fact that this study was a randomized-controlled trial with blind evaluation of the outcomes strongly supports a causal link. The trained physicians provided nutritional advice more often, showed better communication skills, and provided complementary feeding advice more efficiently for caregivers than the untrained physicians.
The CFC training course has several characteristics that could explain its positive effect on physicians’ counseling abilities. Among these characteristics is the generic nutrition counseling guidelines included in the program that were carefully adapted to the local environment. The course also included locally appropriate messages, tools for assessing individual nutritional problems such as feeding of sick or malnourished children, and the development of appropriate counseling skills. Local adaptation of the CFC course enables health workers to engage in specific rather than generic discussion with caregivers and to recommend particular foods and advise parents about avoiding locally specific negative practices. These elements facilitate the work of physicians and improve counseling results. Furthermore, the CFC course aided the development of communication skills of the counseling physicians. They were taught to appreciate the importance of praising the caregivers for positive features of their behavior, using simple language, and to check their understanding of the advice and recommendations 10–12. The CFC course provided physicians essential up-to-date information about nutrition, including the scientific rationale of recommended practices. It also provided them with practical, locally relevant suggestions that they could use in their counseling 13.
We believe that these collective factors aided the success of the counseling process. It should be noted that in the present study, most of the physicians in the control group (70%) received in-service the IMCI training course. The difference noted between the counseling abilities of the physicians who received the CFC course compared with those who received the IMCI training course, despite the fact that the main nutritional training guidelines in both courses are similar, can be attributed to two main differences between the two courses: first, the CFC training was given as a separate course, independent of the other modules in the IMCI program, and second, the number of hours devoted to the CFC feeding counseling was three times greater than that devoted to the nutrition module in the IMCI program. Part of this additional time was devoted to more nutritional counseling skill development and the rest to providing the physicians with more basic information about the scientific rationale for the recommended practices.
Counseling on breastfeeding was little affected by the CFC training. This observation can be attributed to the fact that training on breastfeeding was not new to the intervention and control groups because breast-feeding promotion has been a high priority in Egypt for several decades in the in-service continuing education program of the Ministry of Health and Population MOHP 3, and was also part of the IMCI training that both groups had received.
The observed reduction in recall of feeding messages between the first and the third visits highlights the need for mechanisms to sustain exposure of caregivers to such messages. As only one assessment of the physicians’ performance was performed, and this occurred within 1 month of training, we are unable to report how long they retained the improved feeding counseling knowledge and skills. Contacts of mothers/infant pairs with the health services also tend to reduce after infancy, decreasing the opportunities for the reinforcement of feeding messages through the health services. We believe that another channel of education that can be used for promotion of improved complementary feeding is television. If well designed and with broadcasting timed according to the viewing habits of the caregivers, televisions spots or programs could potentially be a lively, modern, colorful, and attractive channel for the message to reach the families 14. A similar approach was used successfully in Egypt for the promotion of oral rehydration solution for acute diarrhea control and for the vaccination program 3.
However, face-to-face contact through PHC centers, or by home visits by health workers, would enhance proper complementary feeding. Meanwhile, the use of home-based and community-adapted complementary foods can be a cost-effective method, especially in communities where food is available year-round as is the case in the Ismailia governorate in Egypt.
The intervention was successful in improving caregivers’ feeding knowledge and practices, especially those dealing with complementary feeding, in the short term. Despite the disappearance of these recall differences between the intervention and the control groups 6 months after the first counseling session, there was a positive difference in the growth of the children in the intervention group.
In this study, our main goal and focus was to improve the growth of the children through improving feeding practices, particularly with respect to increasing the low energy intake and by improving complementary feeding in the second 6 months of life. We encouraged children caregivers’ to give their children locally appropriate complementary foods including animal-origin foods rich in micronutrients, and we also stressed on individual behavior change more than providing knowledge. Despite the short duration of the intervention, it showed a positive impact on the growth of the children.
The study showed that 6 months after enrollment of the children, those in the intervention group had less growth faltering in weight-for-age, in weight-for-age Z-score, and in weight-for-length Z-score compared with the control group. This difference was especially observed in the children who entered the study at 6–9 months of age in terms of weight-for-age. This observation suggests the importance of feeding counseling at that age group, when mothers start complementary feeding of their children and are most uncertain about what foods to offer and in what amounts. The lack of a significant effect on the linear growth of the children could be because of the relatively short duration of the study as weight responds faster to intervention than length. Therefore, a longer follow-up period might have been required to observe detectable differences 11,15,16.
Three efficacy studies carried out in Brazil, Pakistan, and China used a methodology similar to ours; however, they designed their own complementary counseling training courses. They provided nutritional counseling without food supplements and reported results similar to ours 15–17. The intervention groups had significantly less growth faltering than controls when measured 6 months after feeding counseling. However, a study carried out in India reported a small, but significant, effect on length gain in the intervention group, but no effect in weight 18. Factors that limited physical growth could be related to the availability of appropriate nutritional foods in the community and the baseline characteristics of the participants. Under these circumstances, where food availability is a major constraint, it is advised to couple feeding counseling with supplemental food. A recent review article reported that 17 studies that used such combination approaches reported a significant improvement in weight and length in the intervention groups 19.
Conclusion and recommendations
Our study confirmed the feasibility of improving complementary feeding practices through existing health services in the community, even without food supplements to the families, when delivered in a setting without major problems in access to food. Therefore, we recommend strengthening this element in the IMCI training course in Egypt, which is the main in-service training program in the PHC setting. In addition, the use of the complementary feeding course should be considered for the training of other types of health workers whose main function is the provision of feeding counseling to mothers of young children. We also recommend continuous monitoring and supervision of PHC workers to increase the sustainability and impact of the program.
The positive impact on infants’ growth of this course has confirmed the importance of coupling locally adapted best practices with strengthening of counseling skills. This will have important implications for future nutrition training planning as it could be an effective way to organize and prepare the content and methodology of in-service training programs 12,16,20.
Study strengths and limitations
The positive results of the CFC training program were facilitated by the generic nutrition counseling guidelines included in the program that were carefully adapted to the local environment. The course also included locally appropriate messages, tools for assessing individual nutritional problems such as feeding of sick or malnourished children, and appropriate counseling skills. This observation showed that the generalizability of these results depends on careful adaptation of the program to the local culture and environment.
Furthermore, the observation that mothers’ recall reduces over time is an important reminder that interventions need to be re-enforced to have a sustained benefit. The need for continued monitoring and supervision of trained health workers to facilitate sustainability of good counseling practices should not be disregarded.
The limitations of the study include the assessment of practice by the mother’s recall instead of direct observation, mostly because of the difficulties in the field work. We also did not use the WHO growth charts for the evaluation of children’s growth. Furthermore, we did not use the ‘intention-to-treat’ principle in the data analysis.
The authors thank the team that conducted the training of trainers (TOT) course: Dr Suzanne Farhoud (WHO/EMRO/CAH), Mrs Manal Al-Sairafi (WHO/STC), and Dr Bernadette Dealmans (WHO/HQ/CAH). They also thank master trainers who trained the health providers Prof. Magdy Omar, Prof. Mohamed Naguib Massoud (Alexandria University), Dr Mohey El-Din Maged (Al-Azhar University), Dr Mona Rakha, and Dr Mohamed Abdel-Moniem (MOHP, IMCI). They acknowledge the participation and cooperation of the Ministry of Health and population (MOHP) of the Ismailia governorate, Egypt. Special thanks are due to the residents of the Primary Health Care Units in Ismailia governorate and the units personnel. The authors are indebted to all the families that participated in the study for their kind cooperation.
The research described in this paper was carried out under the Research Grant Agreement (03013 HNI) between WHO/HQ/CAH and the Faculty of Medicine, Suez Canal University, Egypt.
Conflicts of interest
There are no conflicts of interest.
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