A 2-Year Integrated Agriculture and Nutrition and Health Behavior Change Communication Program Targeted to Women in Burkina Faso Reduces Anemia, Wasting, and Diarrhea in Children 3-12.9 Months of Age at Baseline: A Cluster-Randomized Controlled Trial

"...agriculture training and specific BCC activities aimed at empowering women with skills and knowledge that can have both short- and long-term benefits for the women themselves and for their present and future children."

Nutrition-specific interventions to improve growth and reduce anaemia in Burkina Faso are needed, as are efforts to simultaneously address the underlying determinants of malnutrition through multi-sectorial nutrition-sensitive programmes. This study assessed the impact of Helen Keller International (HKI)'s 2-year integrated agriculture [homestead food production (HFP)] and nutrition and health behaviour change communication (BCC) programme on children's anthropometry (stunting, wasting, and underweight), mean hemoglobin (Hb), anaemia, and diarrhoea prevalence.

Implemented from 2010-2012 in the province of Gourma, HKI's enhanced HFP (E-HFP) programme was designed to reach households with women and children in the first 1,000 days of life through 2 primary components: (i) agriculture production activities, and (ii) a nutrition and health BCC strategy. The former (i) included input distribution (e.g., seeds, saplings, chicks, and small gardening tools) and agriculture training provided by 4 female village farm leaders at demonstration farms. After receipt of inputs and training, programme beneficiaries started their own HFP activities. As part of the BCC strategy (ii), participating women received home visits twice a month from either an older woman leader (OWL) or a health committee (HC) member, during which they learned about the optimal practices and discussed successes and challenges related to adoption of these practices.

As part of the cluster-randomised controlled (RCT) trial, 55 villages were randomly assigned to a control group (n = 25) or to 1 of 2 treatment groups (n = 15 each), which differed by who delivered the BCC messages (either OWL or HC members]. The researchers used difference-in-difference (DID) estimates to assess impacts on child outcomes in the 1,767 participating households.

The RCT found marginally significant (P < 0.10) impacts on Hb (DID: 0.51 g/dL; P = 0.07) and wasting [DID: -8.8 percentage point (pp); P = 0.08] and statistically significant (P < 0.05) impacts on diarrhoea (-15.9 pp; P = 0.00) in HC compared with control villages among children aged 3-12.9 months and larger impacts for anaemia (DID: -14.6 pp; P = 0.03) and mean Hb (DID: 0.74 g/dL; P = 0.03) among younger children (aged 3-5.9 months). However, there were no significant impacts on stunting or underweight prevalence.

Along the 2 primary programme pathways examined in this study - that is, from production of micronutrient-rich foods to intake, and from improvements in knowledge to adoption of optimal infant and young child feeding (IYCF) practices - the researchers found statistically significant positive impacts on some key intermediary outcomes. For example, in HC and OWL villages compared with control villages, the RCT found statistically significant greater increases in women's production of the foods primarily promoted by the E-HFP activities. In addition, there were significantly greater improvements in women's knowledge of IYCF practices and in the percentage of women who reported washing their hands before feeding their child. These changes translated into marginally statistically significant greater increases in household dietary diversity scores (DID: 0.8; P = 0.07) and in the percentage of children between 6 and 12.9 months of age at baseline who received 4 or more food groups (minimum dietary diversity) in the past 24 hours (DID: 12.6 pp; P = 0.08) in the HC villages than in the control villages.

Among the explanations for the relatively modest impacts found: the short duration of the programme and the lag time between the baseline survey and full programme implementation, which meant that children likely did not fully benefit from all programme components (including availability of vegetables grown in the home gardens and increased knowledge from the BCC intervention) until they were between 11 and 20.9 months of age. These findings highlight 3 programme design and implementation aspects that could help maximise impact: targeting, timing, and intervention package (to address some of the severe socioeconomic and food access constraints faced by the population).

With regard to the finding that the HC group was effective at improving children's nutritional status whereas the OWL group was not, qualitative data from a process evaluation indicated that HC actors were more knowledgeable about anaemia-related topics than OWL actors and that HC actors generally felt more confident in their knowledge and were more likely than actors in OWL villages to follow up with their beneficiary women to check adoption of optimal practices.

In conclusion: "Given the positive short-term impacts on children's nutrition outcomes and the potential for longer-term benefits for participating women and their families, evaluations of gender-sensitive integrated agriculture and nutrition programs should be performed over longer periods than the 2 y[ears] allocated here to unveil their real potential to contribute to improving maternal and child nutrition."