Phase II
The encouraging trend in the anthropometric data, coupled with positive feedback about the ease of use and understanding of the MUACz, guided the design of the study in Phase II. The project team invited all 140 caregivers of children who were eligible to participate from the Jorasanko community center and 88 chose to participate. Working parents were less likely to participate in the study and in the nutrition program in general. Demographics and baseline nutritional status of Phase II participating children are presented in Table 3. No significant differences were observed between groups in terms of age, gender, language spoken, baseline BMIz, or caregiver participation in the nutrition education sessions. The prevalence of stunting and having younger siblings approached statistical significance between groups; over half (55%) of the MUACz + SupF group had younger siblings, whereas only 15% of the traditional program group did. Stunting was also more likely in the two MUACz groups (MUACz with traditional program and MUACz + SupF).
Table 3
Phase II Demographic characteristics across groups
|
Traditional
(N = 20)
|
MUACz
(N = 21)
|
SupF
(N = 27)
|
SupF + MUACz
(N = 20)
|
P-value
|
Completed Program
|
20 (100%)
|
21 (100%)
|
25 (93%)
|
19 (95%)
|
0.99
|
Age
|
10.1 (8.9–10.6)
|
11.3 (9.8 to 11.8)
|
9.8 (9.4 to 11.3)
|
10.5 (10.2 to 11.3)
|
0.18
|
Gender
|
|
|
|
|
0.90
|
Male
|
9 (45%)
|
9 (43%)
|
14 (52%)
|
11 (55%)
|
|
Female
|
11 (55%)
|
12 (57%)
|
13 (48%)
|
9 (45%)
|
|
Language
|
|
|
|
|
0.38
|
Bengali
|
2 (10%)
|
3 (14%)
|
4 (15%)
|
0 (0%)
|
|
Hindu
|
17 (75%)
|
18 (86%)
|
20 (74%)
|
18 (90%)
|
|
Urdu
|
1 (5%)
|
0 (0%)
|
3 (11%)
|
0 (0%)
|
|
Younger Siblings
|
3 (15%)
|
6 (29%)
|
8 (30%)
|
11 (55%)
|
0.06
|
Attended Caregiver Education
|
13 (65%)
|
12 (57%)
|
16 (59%)
|
13 (65%)
|
0.94
|
Baseline BMIz
|
-2.2 (-2.7 to -2.0)
|
-2.2 (-2.7 to -1.9)
|
-2.5 (-2.8 to -2.3)
|
-2.2 (-2.7 to -1.9)
|
0.30
|
Stunting
|
5 (25%)
|
14 (67%)
|
10 (37%)
|
13 (65%)
|
0.06
|
Adjustments Made During Phase II
This longer Phase included predetermined checkpoints with caregivers every 2.5 months, which resulted in three iterations over the 7.5 month long study. During the first check in, SupF and MUACz + SupF groups shared children’s dissatisfaction with the nutritional supplement, which resulted in project team connecting with CINI to offer additional flavors and suggestions for preparation to caregivers. In the second check in a refresher training was provided on using MUACz and the tracking card per caregivers’ request.
Phase II Qualitative Feedback: MUACz Tape
In Phase II, 85.0% (34/40) of the participants given the MUACz used it to monitor their child’s nutritional status throughout the study. Of those users, 53.0% of participants reported that it was “Very easy” or “Somewhat easy” to use. Only 82.3% of all participants in Phase II said it was “Very easy” or “Somewhat easy” to understand nutritional risk with the tape compared to 100% of participants in Phase I. Half of the caregivers (50.0%) in Phase II reported making decisions or changes concerning care for their child based on the MUACz and tracking sheet. Few participants reported dissatisfaction with the program and use of the MUACz (2.9%). Among the difficulties listed were that the tape was difficult to use, was misplaced, and parental absence during training or study period.
Phase II Qualitative Feedback: SupF
All participants in Phase II who completed the study in the SupF or MUACz + SupF groups completed a survey about their experiences using the SupF at home. These surveys elucidated some tolerance and dissatisfaction issues with SupF. Although 100% of the participants in the SupF and MUACz + SupF groups who completed the study had consumed the SupF powder, there was a significant association between reported level of child’s satisfaction with the SupF and study group (P = 0.04), with MUACz + SupF caregivers reporting much higher levels of dissatisfaction (65.0% vs 33.3%). Caregivers of children in the SupF group reported their children were “neither satisfied nor dissatisfied” more often than MUACz + SupF (29.6% vs 0.0%). While not significant, MUACz + SupF caregivers reported using the SupF only a few times during the study period compared to the SupF group (35.0% vs 11.1%, respectively). Dissatisfaction was significantly associated with lower frequency of use (P < 0.001), as well as higher rates of rejection of the supplement (P < 0.001). No caregivers reported difficulty in preparing the SupF, and 91.5% reported that it was “Very easy.” Age, preparation, and group were not significantly associated with supplementary food dissatisfaction; however, 80.0% of those who were dissatisfied with the SupF were taking it either at breakfast or as an evening snack. As dinner is typically eaten later and is the biggest meal of the day in the community, these two times would typically represent the longest fasting periods of the day, hence a potentially empty stomach.
Phase II Quantitative Anthropometric Data
The interaction term between time and group was only marginally significant (χ9 = 15.58, P = 0.08). However, the results of the general linear hypothesis testing showed that on average the MUACz + SupF group experienced a change in BMIzs 0.52 standard deviations higher when compared to the SupF at the end of the study (95% CI: (0.10, 0.96); |Z|=3.31, P = 0.01). The MUACz + SupF compared to the MUACz with traditional program was marginally higher by 0.40 standard deviations, but not statistically significant (95% CI: (-0.03, 0.85); |Z|=2.49, P = 0.06). The SupF group was the only group that displayed statistically significant, unexpected decrease in BMIz after controlling for other covariates, exhibiting a BMIz − 0.38 standard deviations lower in December than in May 2019 (95% CI: (-0.67, -0.08); |Z|=3.46, P = 0.005).
Height-for-age Z-scores were examined a posteriori to determine whether disproportionate gains in height relative to weight over the study period may have contributed to the BMI findings. However, there was no significant difference between MUACz + SupF and the SupF group in terms of change in height-for-age Z-scores (|Z|=0.02, P ≈ 1.00). Thus, an accelerated gain in height without commensurate weight gain is unlikely to explain the observed differences in BMIzs for MUACz + SupF and the SupF groups
Focus Group Discussions at End of Phase II
Four focus groups were conducted, one per experiment group, with a minimum of 8–9 enrolled mothers in each group. Discussions were audio recorded with verbal consent and later transcribed. Themes were identified through in-vivo coding. Two additional coders reviewed the results in order to ensure quality of the emerging themes.
While quantitative measurement did not reflect significant gains in nutritional status across groups, FGDs revealed that mothers in the intervention groups (i.e. MUACz, SupF, MUACz + SupF ) perceived changes in their children’s health after the study. These included increase in height and weight, fewer illnesses, and improvements in overall appearance.
“Nowadays my child doesn’t get ill frequently” – Respondent, MUACz + SupF Group
“My child used to be very weak earlier, after having the powder from last few months, she now feels strong” – Respondent, SupF Group
Additional caregiver observations for children in the MUACz + SupF group included improvement in academic activities.
“She is now regular in her school and tuitions. Earlier she used to be irregular” - Respondent, MUACz + SupF Group
A few respondents across the groups however mentioned they were not aware of or did not notice improvement in child’s health after this experiment.
During the FGDs, almost all the mothers in MUACz and MUACz + SupF group reported use of MUACz tape at least twice in the last seven and a half months. When asked about the reasons of not using the tape every month, responses included forgetfulness and lack of time due to other household activities. A few mentioned difficulties in recalling the proper usage of the tape; however, several noted that their children assisted when they forgot the process.
“Children are fast learner they remember everything quickly” - Respondent from MUACz group
In comparison to height and weight measurement at the center, the majority of respondent cited convenience with immediate feedback, and the ability to monitor other children at home were cited as a benefit of the MUACz.
It is better, we can easily measure at home anytime, and we do not have to come to the center repeatedly. – Respondent, MUACz Group
“We can measure for other siblings as they don’t get their height weight measured in the center” - Respondent, MUACz + SupF Group
Nearly all mothers were able to confidently state the meaning of the different colors in regard to nutritional status
“Yes, colors are easy, red means bad, orange means medium and green means good, we have to reach to green color”- Respondent, MUACz Group
Almost everyone tracked the progress using the tracking card; the colors on the card helped caregivers to visualize the progress or decline. Children helped their mothers to record the date of measurement on the tracking card.
During the FGD, mothers shared that majority of the children consumed the supplementary food only once or twice during the duration of the study. Few had completed the whole packet of supplementary food over the 7.5 month period. The reasons shared by the respondents were disliking the taste and flavor of the SupF. In addition, one month of festival during the study period may have contributed to some of the children inconsistently consuming the SupF.
Dissatisfaction with taste was reported in both the SupF and MUACz + SupF groups. However, all the mothers were aware of the importance of the supplementary food and tried their best to encourage the child to consume it, using different preparations such as with water, milk, homemade bread, or pulses.
“My child did not intake the powder hence no progress was seen on the tracking card”- Respondent MUACz + SupF Group
The use of the supplemental tracking cards was less than that of the MUACz tracking cards in the MUACz groups. Reasons stated were mainly around frequency; the nutritional supplement tracking card required daily reporting, whereas MUACz tracking card was only required once a month. Often, tracking cards were misplaced, or damaged, as the paper quality was inadequate to sustain storage impacts.
The level of care and decisions at the household level were higher among the MUACz and SupF groups. The range of care and decisions on child stated by the mothers were providing timely food to the children, preventing them from eating unhealthy street food, preparing interesting food items with vegetables, which they learned from education sessions, or incorporating one egg daily into the child’s diet.
Many reported consulting doctors, inquiring about vitamin tablets and health drinks to support the growth of child. Communicating with outside medical professionals about their child’s health suggests increased knowledge, engagement, and agency in the care of their child.
“I have visited the CI clinic many times and asked the doctor to give vitamin tablets to my child but the doctor did not provided any tablet and asked me to feed homemade food” - Mother, MUACz Group
“…. I have also visited and asked the doctor to write in the prescription some health drinks which will increase height of my child” - Mothers, MUACz Group