Population: Children under-five in low and middle-income countries (or studies where the
majority of children were under-five during the intervention). Although children under-two are a key age group for nutritional intervention ‘under-five’ is a widely recognised group and is likely to have been the focus of several interventions. I have limited studies to low and middle- income countries because this is where the major burden of undernutrition is and interventions may not be comparable between lower and higher income countries.
Intervention: Community-based behaviour change interventions. ‘Community-based’ includes
the household-level up to primary healthcare. I excluded interventions with facility-based components according to the Lancet definition described above (Darmstadt et al. 2005). ‘Behaviour change interventions’ were defined as interventions aiming to change specific behaviour(s) in individuals, families or communities to promote child growth or reduce undernutrition. Interventions must have involved at least one element of behaviour change. Possible approaches were health education, participatory interventions, direct psychosocial inputs such as developmental stimulation and indirect approaches such as cognitive behavioural therapy for maternal depression. Other interventions involving at least one element of behaviour change and satisfying the above criteria were also considered. Health education, behaviour change communication, community mobilisation, positive deviance, cognitive-behavioural therapy, responsive feeding and conditional cash transfer programmes are defined in Box 2.1.
Control: Acceptable comparison groups included: no intervention/standard care, alternative
interventions (e.g. food supplements) or other behaviour change interventions.
Outcomes: Linear or ponderal growth outcomes measured at baseline and end-line. Specific
growth outcomes included: weight or weight-for-age Z-score (WAZ), length/height or length/height-for-age Z-score (LAZ/HAZ), weight-for-height/length Z-score (WLZ/WHZ) and mid- to-upper arm circumference. Studies that only included birth weight or intrauterine growth restriction outcomes were excluded. Whilst these are critical nutrition outcomes, the focus of this thesis is on child growth beyond the immediate postnatal period.
49 Organisation of Care Review group acceptable study designs were: randomised controlled trials, non-randomised controlled trials, controlled before-and-after studies (i.e. baseline and end-line measurements for intervention and control groups), interrupted time series and repeated measurement studies (Effective Practice and Organisation of Care (Cochrane) review group 2011).
I restricted articles to those published in English since 1990. The following studies were considered beyond the scope of this review: cost-effectiveness studies, evaluations of emergency nutrition programmes involving special features and settings (e.g. refugee camps, Community Management of Acute Malnutrition), obesity prevention, interventions reliant upon phone technologies, interventions solely focused on food provision or micronutrient supplementation, agricultural and food security interventions, and media/social marketing interventions. There were no exclusions as to the cadre or training level of health workers that may have delivered interventions. Multiple articles reporting on the same participants and intervention were treated as one study.
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Box 2.1 Definitions of selected community-based behaviour change approaches
a. Health education: ‘Communication of information, fostering the motivation, skills and confidence necessary to take action to improve health…and the communication of information concerning the underlying social, economic and environmental conditions impacting on health, as well as individual risk factors and behaviours, and use of the health care system’ (World Health Organisation 1998)
b. Behaviour change and communication (previously ‘information, education and communication'): Aims to ‘achieve or consolidate behaviour or attitude changes in designated audiences, using a combination of communication technologies, approaches and processes in a flexible and participatory…systematic and well researched manner’. Further requirements are ‘supportive social environments’ and the role of ‘expert’ re-defined as ‘communicator’ for sustainable behaviour change or social norm change (UNICEF 2006)
c. Community mobilisation: ‘A capacity building process through which community members, groups or organisations plan, carry out and evaluate activities on a
participatory and sustained basis to improve their health and other conditions, either on their own initiative or stimulated by others’ (Howard-Grabman 2007)
d. Positive Deviance and undernutrition: Caregivers whose children thrive despite socio- economic adversity and high community-levels of undernutrition are assumed to have uncommon ‘positive deviant’ caring and feeding behaviours. The positive deviance approach recruits these caregivers to teach other community members how to use local, affordable, nutritious and uncommon foods. Positive deviance also has a social mobilising function: people are motivated to learn about solutions from within the community, rather than feeling criticised about local practices by external actors (Marsh et al. 2004)
e. Cognitive-behavioural therapy: Counselling sessions using active listening and guided discovery techniques aim to change negative cognitions and maladaptive behaviours, and encourage participants to explore and test alternative thoughts and behaviours as homework (Rahman et al. 2008)
f. Responsive feeding: Based within a Responsive Parenting framework, it ‘reflects reciprocity between child and caregiver’. It comprises four stages: 1) caregiver provides an interaction promoting environment 2) child ‘responds and signals’ to the caregiver 3) caregiver responds rapidly, in a developmentally appropriate and emotionally supportive way 4) ‘child experiences predictable responses’ (Black and Aboud 2011) g. Conditional cash transfers: cash transfers by governments to individuals or households
to reduce income poverty, often within wider social protection programmes. Conditional transfers are contingent on particular behaviours (e.g. attendance for nutritional counseling), whilst others may not have conditions attached (Save the Children 2009)
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