Research Article

A Community-Based Positive Deviance/Hearth

Infant and Young Child Nutrition Intervention in
Ecuador Improved Diet and Reduced Underweight
Marion L. Roche, PhD1,2,3; Grace S. Marquis, PhD2,3; Theresa W. Gyorkos, PhD4,5;
Brittany Blouin, MSc4; Julieta Sarsoza, MD6; Harriet V. Kuhnlein, PhD2,3

ABSTRACT
Objective: Underweight and stunting are serious problems in Ecuador that require interventions in the
first 2 years of life. The researchers assessed the effectiveness of a Positive Deviance (PD)/Hearth community-
based intervention using local foods to improve infant and young children’s nutrition.
Design: A quasi-experimental nonrandomized study was conducted between March and October, 2009.
Setting: The intervention and study were implemented in the Ecuadorian highlands provinces of Chim-
borazo and Tungurahua.
Participants: Eighty mother–child pairs in 6 intervention communities and 184 mother–child pairs in
9 comparison communities.
Intervention: Mothers met in participatory peer-led PD/Hearth cooking and nutrition education sessions
for 12 days.
Main Outcome Measures: Dietary intake and nutritional status were collected at baseline and 6-month
follow-up.
Analysis: Multiple linear and logistic regression were used for growth outcomes, and ANCOVA for
mean dietary intakes.
Results: Mothers in the intervention were 1.3–5.7 times more likely to feed their children the promoted
foods (P < .05). Children in the intervention consumed a higher percentage of recommended intakes for
iron, zinc, vitamin A, protein, and energy (P < .05) at follow-up and had improvements in weight-for-age
z-score (b ¼ .17; 95% confidence interval, 0.01–0.31). Likelihood of underweight was reduced for children
in the intervention (odds ratio ¼ 0.36; 95% confidence interval, 0.13–0.96)
Conclusions and Implications: The PD/Hearth interventions support mothers to improve infant and
young children’s nutrition practices and reduce underweight.
Key Words: nutrition intervention, child, complementary feeding, Positive Deviance/Hearth, under-
weight, local foods (J Nutr Educ Behav. 2016;-:1-8.)
Accepted October 8, 2016.

INTRODUCTION
Despite progress toward the millen-
nium goals, like many developing coun-
1
Research & Evaluation Unit, Micronutrient Initiative, Ottawa, Ontario, Canada tries, Ecuador fell short of meeting the
2
Centre for Indigenous Peoples’ Nutrition and Environment, McGill University, Ste-Anne- nutrition millennium development goals.
de-Bellevue, Quebec, Canada Underweight and stunting rates remain
3
School of Dietetics and Human Nutrition, McGill University, Ste-Anne-de-Bellevue, of public health concern. Additional stra-
Quebec, Canada tegic investmentswill beneededinEcuador
4
Division of Clinical Epidemiology, McGill University Health Centre, Quebec, Canada to achieve the nutrition targets of the
5
Department of Epidemiology, Biostatistics and Occupational Health, McGill University, sustainable development goals.1 Identi-
Montreal, Quebec, Canada fying successful infant and young child
6
World Vision Ecuador, Quito, Ecuador feeding interventions is critical in Ecuador,
Conflict of Interest Disclosures: The authors’ conflict of interest disclosures can be found online because rates of underweight and stunt-
with this article on www.jneb.org. ing are among the highest in Latin America
Address for correspondence: Marion L. Roche, PhD, Micronutrient Initiative, Research and and reductions in malnutrition have not
Evaluation Unit, 180 Elgin St, Ste 1000, Ottawa, Ontario, Canada K2P 2K3; Phone: (613) paralleled economic growth.2 Although
782-6822; Fax: (613) 782-6838; E-mail: roche.marion@gmail.com recent social assistance programs in Ecuador
Ó2016 Society for Nutrition Education and Behavior. Published by Elsevier, Inc. All rights have been popular, they have neither
reserved. included strong nutritional components
http://dx.doi.org/10.1016/j.jneb.2016.10.007 nor resulted in nutritional improvements,3

Journal of Nutrition Education and Behavior  Volume -, Number -, 2016 1

2 Roche et al
as seen in Mexico's Oportunidades pro-
gram.4,5 Although nutrient gaps may be
addressed with supplements,6 food-based
approaches with local foods offer po-
tential for acceptability and sustainable
behavior change.7,8 Positive Deviance
(PD)/Hearth is a community-based partic-
ipatory nutrition education approach
rooted in the Health Belief Model. Pos-
itive Deviance/Hearth is designed to improve
nutrition and a mother's self-efficacy
for infant and young children's nutri-
tion through practicing positive feeding,
hygiene, and caring practices existing
within communities and replicating
these practices with mothers in cooking
sessions led by their peers.9 Although
the PD/Hearth approach has been im-
plemented across developing countries,
evaluations of its effectiveness and
conditions for success are limited.10,11
The objective of this study was to eval-
uate the effectiveness of a community-
based PD/Hearth intervention to improve
diet and growth and thus reduce under-
weight and stunting in infants and young
children aged <2 years in the Ecuador-
ian Andes.
METHODS
Study Overview and
Participants
A quasi-experimental, nonrandomized
designandcensus-stylerecruitmentenabled
a comparison of malnutrition indices
between infants and young children
aged <2 years in rural communities who
received the PD/Hearth intervention
with those of the same age in similar
comparison communities who did not
receive the intervention. Community
leaders selected comparison commu-
nities selected based on similar socio-
economic status (SES), wealth indices,
health infrastructure, access to water,
average ownership of small animals,
distance from main roads, and occupa-
tions of males in the community, with
consideration for the population to pro-
vide an approximate 1:2 ratio of inter-
vention to comparison for mother–child
pairs. Six intervention communities (3 in
Tungurahua and 3 in Chimborazo) and
9 comparison communities (5 in Tung-
urahua and 4 in Chimborazo) were
selected. Invited participants included
all mothers and their infants and
young children aged <24 months in
each community. They were identified
through birth registries, community
Journal of Nutrition Education and Behavior  Volume -, Number -, 2016
lists, midwives, and community leaders. time of day agreed upon by the group.
The intervention was implemented in In each community, 3–4 menus were
communities in the Ecuadorian high- repeated throughout the 12-day Hearth
lands, with 2-week peer cooking sessions sessions, including boiled broad beans
followed by biweekly peer home visits. with cheese and colored potatoes (pu-
Measurements were taken at 2 time reed for younger children); eggs, nettle,
points: baseline before the interven- and cheese omelet; blackberry and oat
tion (March to April, 2009) and at 6- puree; nettle, tuna, and flour tortillas
month follow-up to the peer cooking (pureed for younger children); and thick
sessions (September to October, 2009). quinoa soup with nettle and tuna/
chicken/liver/guinea pig or mixed beans.
Snacks were large broad beans, lupin
Intervention seeds, cheese, blackberries, and bananas.
Mothers were encouraged to add avail-
World Vision Ecuador implemented the able nutritious, commonly eaten foods
PD/Hearth nutrition education interven- such as carrots, onions, leafy greens, and
tion after conducting a PD inquiry (PDI) peas. Each mother contributed an ingre-
to identify local positive feeding, caring, dient to the cooking session, as was
and hygiene practices, by visiting and agreed upon by the group on the previ-
conducting household observations of ous day. Preparing thick purees (hand-
12 families of well-nourished children mashed with a fork or spoon) for infants
(weight-for-age z-score [WAZ] > –1) and younger children (aged 6–12 months),
without extra resources.9 Table 1 presents rather than the customary watery soups
key positive deviant practices identi- or broths, and increasing consistency
fied through the observations and in- for children aged 12–24 months was
terviews. The results of an initial nutrition emphasized. Hand washing, kitchen
assessment and PDI were presented at hygiene, and healthy food preparation
communitymeetings.Communityleaders were taught through practice. For example,
nominated madre guias (volunteer peer- a madre guia ensured that each mother
educators) who had the respect of peers washed her own hands and her child's
in their community, $2 children, and hands and face with warm water before
healthy-weight children (WAZ > –1 eating (taking from the cooking pots).
and WAZ <2). Participatory training Participants and the guide mother ensured
included basic nutrition and healthy recipe that animals did not enter the kitchen.
preparation using local foods identi- Mothers were encouraged to sit with
fied in the PDI, interpretation of weight their children and feed them the meal
gain and growth curves, food hygiene, as part of contextualized responsive feeding
responsive feeding, and group organi- messages. After feeding, guide mothers
zation and facilitation. Mothers of discussed 1–2 key messages with the
children aged <2 years brought their group; the madre guias had the use of
child to the house of the closest madre a flip chart with 12 images designed
guia for 12 consecutive days, where they by a local artist. For mothers of chil-
met with 8–12 mother–child pairs for dren aged <6 months, the madre guias
2 hours to prepare a healthy meal at a recommended exclusive breastfeeding;
Table 1. Key Intervention Positive Deviance Practices and Messages
Dietary diversity
I give my child a variety of local foods daily
Together we are making new recipes with local foods
Timely introduction and consistency
At 6 mo I start to feed my baby papillas (purees), not just broth
Responsive feeding
I sit with my child when she eats and feed with love and affection
Hygiene
We wash our hands and my child’s hands and face with warm water before
cooking and eating
We keep animals out of the kitchen
Exclusive breastfeeding
Breast milk is everything my baby needs until 6 mo
Journal of Nutrition Education and Behavior  Volume -, Number -, 2016
she offered lactation advice and sug-
gested that mothers wait until a child
had reached age 6 months before giv-
ing complementary foods, herbal rem-
edies, or teas. For mothers in formal and
informal agricultural work, exclusive
breastfeeding was enabled by the cul-
tural practice of wearing infants and young
children in a wrap on the mother's back.
Madre guias made home visits to partic-
ipants' homes every 2 weeks for 4 months
after the 12-day nutrition cooking sessions.
The comparison communities received
only brief (approximately 5-minute)
nutritional counseling at baseline.
Anthropometry and Health
Children were weighed using hanging
Salter scales (Model 235; Salter Breck-
nell, Fairmont, MN) that were calibrated
daily and tared to zero with the weigh-
ing hammock before each child was
measured. The supervising researcher
and an additional nutritionist recorded
weight with a precision of 0.1 kg in
duplicate to reduce interobserver er-
ror. All measures differing by $0.2 kg
were remeasured by both; otherwise an
average was taken. Children's weights
were adjusted for clothing weight using
a detailed individualized list of clothing
items, and a reference list was established
throughout the study. Two trained nu-
tritionists measured all children's recum-
bent lengths in duplicate with a precision
of 0.1 cm on a wooden recumbent sta-
diometer made and calibrated in Quito.12
Mothers were asked their child's birth
date, which was confirmed either on
the child's immunization and growth
monitoring card or in the local birth
registry when a child did not have a
health center document. Sex-specific
WAZ and length/height-for-age z-scores
(LAZ/HAZ) were calculated using World
Health Organization Anthro software
(beta version, Anthro 2005, World Health
Organization, Geneva, Switzerland, 2006)
and all HAZ were reflective of LAZ for
recumbent measurements. Nutritional
status (WAZ and HAZ) was classified
as moderate (–3 # z-score < –2) and se-
vere (z-score < –3). Underweight and
stunting prevalence calculations used
the proportion of children with mod-
erate and severe (z-score < –2).12 At
both interviews, a mother was asked
whether her child had symptoms of
an acute respiratory infection or diar-
rhea within the previous 2 weeks.
Dietary Intake
A community-participatory food sys-
tem assessment helped identify 23 items
for the food frequency questionnaire
(FFQ).13 Foods included staple and cultur-
ally importantfoods,nutritiouslocalfoods,
and market foods. This list included
foods promoted in the intervention,
including the PD foods: quinoa, large
fava beans, lupin seeds, mixed beans,
nettles, blackberries, fresh cheese, guinea
pigs, canned tuna, and liver. With the
exception of the canned tuna and fresh
cheese (produced locally), the foods were
grown by some of the participants and
were traded and purchased at the com-
munity level. Other staples were pur-
chased in the markets. The FFQ was
administered at baseline and follow-up
visits. Specifically, the mother was asked
whether her child had ever consumed
each item, if the child continued to receive
the item, and how often the child ate the
item, and about consumption within the
past 2 weeks.
At both time points, a child's dietary
intake excluding breast milk was re-
corded with a 24-hour recall using the
multiple-pass method.14 Dietary intake
of nutrients was calculated in ProPAN
software (Pan American Health Organi-
zation, Washington, DC, 2004). Dietary
analyses were disaggregated by age
groups (in months): 6–8, 9–11, 12–24,15
and 24–30.16 Mothers were asked about
breastfeeding on the previous day. For
children who were breastfed, an average
intake of breast milk was assumed.15
Nutrient recommendations for non-
breastfed children were applied for chil-
dren whohadnotbreastfedontheprevious
day.15 To compare children across different
age groups, nutrient intakes were con-
verted to the percentage of recommen-
ded intake of complementary foods.
Sociodemographic
Questionnaire
Mothers provided information about
their education, marital status, living con-
ditions, age, and number of children.
Families were also asked about whether
they owned a latrine. Altitude was re-
corded as the elevation at the center
of the child's community.17 An SES
composite score was calculated based
on roof materials, wall materials, floor
materials, access to water, and the source
Roche et al 3
of power in the home; scores ranged
from 3 to 11 and questions were based
on those from national-level surveys.18
Statistical Analyses
Analyses were performed at baseline
to check for pre-intervention differ-
ences between intervention and com-
parison communities. The researchers
used Student t tests to identify differ-
ences in normally distributed contin-
uous variables, Kruskal–Wallis tests for
data that were not normally distrib-
uted, and Mann–Whitney U tests to
identify initial differences in the clas-
sification of nutritional status. The re-
searchers used ANCOVA to compare
the mean percentage of recommen-
ded dietary intake consumed between
the intervention and control groups
while controlling for the child's age
and sex, maternal education, and so-
cioeconomic status. Bonferroni correc-
tions were applied to adjust for multiple
comparisons. Fisher's exact test was
used to compare proportions of children
consuming foods in the FFQ; this was
then confirmed with binary logistic
regression adjusting for age, sex, and
SES. Multiple linear regression was used
to analyze differences in changes in
z-scores (DWAZ and DHAZ), control-
ling for covariates. Logistic regression
was used to assess differences in odds
of underweight (WAZ < –2) and stunt-
ing (HAZ < –2), adjusting for variables
found to be significant in univariate
analyses and that had sufficient vari-
ability, as well as those previously identi-
fied in the literature. To account for
the potential influence of clustering in
the 15 communities, 14 dummy vari-
ables were created for inclusion in
regression analyses. Statistical signifi-
cance was considered at P < .05. All
analyses were performed in SPSS PASW
Statistics 18 (version 18.0.0, SPSS,
Inc, Chicago, IL, 2006).
Ethical Considerations
The McGill University Faculty of Medi-
cine Institutional Review Board in Mon-
treal, Canada, and Ministerio de Salud
Publica Direccion de Nutricion, in Quito,
Ecuador, granted ethics approval. The
authors obtained community consent
through written research agreements,
and mothers gave informed oral consent
4 Roche et al Journal of Nutrition Education and Behavior  Volume -, Number -, 2016

for their children's and their own not differ from the other comparison months, P < .05; and 271  100 kcal for
participation. children at baseline. children aged >18 months, P < .05).
Children in the intervention consumed
a higher percentage of recommended
Dietary Intake
RESULTS intakes for energy, protein, vitamin
At baseline there were no differences in A, iron, and zinc than did comparison
Characteristics of Participants
energy consumption between the inter- children (Figure 1). Mean intakes for
There were 80 mother–infant/child pairs vention and comparison groups. Inter- calcium, vitamin A, and iron were below
in the intervention communities and vention and comparison children met the recommendations. The large SDs
184 mother–infant/child pairs in the a similar percentage of age-specific rec- reflect the use of a single 24-hour recall
comparison communities. The partici- ommended nutrient intakes for protein, and between-individual variability in
pation rate was over 85%. Mothers cited vitamin A, vitamin C, calcium, and iron. intakes.
other commitments as the main reason However, children in the intervention
for declining. Maternal education, SES, consumed a lower percentage of the rec-
Consumption of Foods
and age did not differ between groups. ommended intake for zinc (70% vs 83%;
Comparison children were younger than P < .05). Promoted in Intervention
children in the intervention (Table 2). At follow-up, infants and children in At baseline, there were no significant
After the intervention there was no intervention had higher mean energy differences between groups in the
loss to follow-up for children who intakes than did children in comparison odds of including foods that were pro-
were in the intervention, whereas 18 communities (differences: 178  144 kcal moted in the intervention (not shown).
comparison children were not avail- for infants aged 6–12 months, P < .05; At follow-up, children in the interven-
able at follow-up; however, they did 294  153 kcal for children aged 12–18 tion were more likely than comparison
children to consume 7 of the 10 pro-
moted foods within the previous
Table 2. Selected Characteristics of Intervention and Comparison Children Aged 2 weeks (Figure 2): quinoa (odds ratio
0–2 Y at Baseline in Community Nutrition Intervention Evaluation in [OR] ¼ 2.35; 95% confidence interval
Ecuadorian Andes (March to April, 2009) [CI], 1.18–4.72), large fava beans
(OR ¼ 2.28; 95% CI, 1.01–5.55), mixed
beans (OR ¼ 2.10; 95% CI, 1.01–4.39),
Intervention Comparison
nettles (OR ¼ 5.67; 95% CI, 2.64–
Children Children
12.19), blackberries (OR ¼ 1.59; 95%
Characteristics (n ¼ 80) (n ¼ 184) P
CI, 1.03–3.50), cheese (OR ¼ 2.09;
Altitude (meters above sea level) 2,570  317 2,578  420 .87 95% CI, 1.03–4.27), and liver (chicken
(mean  SD) and beef) (OR ¼ 1.90; 95% CI, 1.01–
SES composite score (mean  SD)a 5.5  1.6 5.3  1.7 .28 3.68), after controlling for age and
Number of children/mother 2.7  2.0 2.9  1.9 .34 maternal education. There were no sig-
(total births) (mean  SD) nificant differences for lupin seeds
Mother’s age, y (mean  SD) 26.4  7.1 27.7  7.3 .20 (OR ¼ 1.43; 95% CI, 0.70–2.94), guinea
Mother’s education, y (mean  SD) 6.6  2.7 6.2  2.8 .27 pigs (OR ¼ 1.31; 95% CI, 0.55–3.15), or
Child’s age at baseline, mo (median 14.5 (6.7–19.5) 10.7 (5.8–16.2) .02* tuna (OR ¼ 1.66; 95% CI, 0.76–3.59).
[interquartile range]) At baseline, the groups reported the
Sex (%) same mean age of introduction to herb-
Female 45.6 49.3 .57 al teas: 6.1  3.0 months (P ¼ .62); at
Male 54.4 50.7 follow-up, infants in the intervention
WAZ (mean  SD) –1.55  1.21 –1.29  1.05 .10 group who were aged <6 months at
HAZ (mean  SD) –2.32  1.34 –2.13  1.32 .28 baseline (n ¼ 17) had a mean introduc-
Underweight (WAZ < –2) (% [n]) 30.4 (24) 23.4 (43) .22 tion age of 7.7  4.4 months whereas
Severe underweight (WAZ < –3) 10.0 (8) 5.1 (9) .13 infants from the comparison group
Stunting (HAZ < –2) (% [n]) 62.0 (50) 54.2 (99) .23 who were younger than 6 months at
Severe stunting (HAZ < –3) 30.4 (24) 25.2 (46) .43 baseline (n ¼ 56) were introduced to
Diarrhea in past 2 wk (% [n]) 18 (14) 23 (42) .35 herbal remedies at a younger age
Respiratory infection in past 42 (34) 38 (70) .57 (6.1  4.0 months; P < .05).
2 wk (% [n])
HAZ indicates height-for-age z-score; SES, socioeconomic status; WAZ, weight- Anthropometry and Growth
for-age z-score.
Note: Student t tests were used to identify differences in normally distributed At follow-up, there was a significant
continuous variables, Kruskal–Wallis tests for data that were not normally distrib- additional weight gain of 0.16 WAZ
uted, and Mann–Whitney U tests to identify initial differences in the classification of (b ¼ .16; 95% CI, 0.00–0.32) in children
nutritional status. in the intervention that remained signif-
a
SES composite score includes walls, floors, power source, and water access; icant (b ¼ .17; 95% CI, 0.01–0.33) after
*Significance at P < .05. adjusting for covariates (Table 3). There
Journal of Nutrition Education and Behavior  Volume -, Number -, 2016 Roche et al 5

Mothers who participated in the

200 PD/Hearth intervention included the
a b promoted foods into the diets of their
180 infants and young children more
frequently than did the comparison
160
mothers. Similar results were found
in an evaluation of a PD/Hearth pro-
% Recommended intake

140
gram in Viet Nam, in which children
in the intervention ate local promoted
120
foods more frequently and were more
100 likely to meet energy requirements.19
The current PD/Hearth evaluation
80 found a positive intervention effect of
0.17 WAZ over 6 months. An evalua-
60 tion of a PD/Hearth nutrition education
program in Haiti showed an increase of
40 0.30 WAZ over 1 year, but the benefit
was limited to children who had mild
20 or moderate underweight at baseline.11
For children aged <15 months in the
0 Viet Nam PD/Hearth intervention, their

n*

c*
WAZs declined by 0.20 less than those
um
*

C
A*
gy

Zin
n

in

Iro
ei

lci

of comparison children.10 Efficacy trials

in

m
er

ot

Ca
m

ta
En

Pr

ta

Vi

have shown increased growth through

Vi

improved complementary feeding by

distributing supplementary foods or in-
Intervenon n=80 Comparison n=184
gredients, which resulted in WAZ in-
creases between 0.25 and 0.44 over a
Figure 1. Mean percentage (SD) of recommended intake from complementary similar time frame. These supplemen-
foods for intervention and comparison infants and young children aged 6–30 months tary feeding interventions increased en-
(n ¼ 264) at 6-month follow-up in a community nutrition intervention evaluation in the ergy intake by 83–317 kcal/d.20 Although
Ecuadorian Andes (September to October, 2009) based on a 24-hour dietary recall. the researchers were limited to data gath-
a
Intervention children’s protein intake was 358%  170%, and comparison children’s ered using a single 24-hour recall,14 they
protein intake was 296%  162%. bIntervention children’s vitamin C intake was estimated that after the nutrition edu-
235%  146% and comparison children’s vitamin C intake was 201%  163%. *Sig- cation sessions, children who participated
nificant differences at follow-up after adjusting for covariates (P < .05). Age-specific in PD/Hearth consumed an additional
recommendations were used to assess dietary intake of vitamins, minerals, and 178–294 kcal/d from local foods that
energy from complementary foods.15,16 For breastfed infants. average intake from mothers prepared at home.
breast milk was assumed.15 Statistical test was ANCOVA, controlling for the child’s The potential for PD/Hearth to have
age and sex, maternal education, and socioeconomic status. longer-term benefits and sustained be-
havior change in communities was re-
ported in Viet Nam. Three years after
was neither a crude benefit of the inter- underweight at follow-up (OR ¼ 0.53; the project ended, younger siblings of
vention on changes in HAZ (b ¼ .03; 95% CI, 0.21–1.22); however, this ef- former participants had increased feeding
95% CI, –0.15 to 0.23) nor an effect in fect was significant after controlling frequency, improved hand washing,
multivariable analyses (b ¼ .00; 95% for covariates (OR ¼ 0.36; 95% CI, and higher WHZ and WAZ than did
CI, –0.21 to 0.17) when controlling for 0.13–0.96) (Table 4). children of the same age who did not
covariates. have mothers who had previously
The prevalence of underweight participated with older siblings.21 The
(WAZ < –2) in the intervention group DISCUSSION repetition of menus in the PD/Hearth
decreased from 30.4% at baseline to program may have been an effective
23.7% at follow-up, and the prevalence In this evaluation of a community- behavior change strategy for increasing
of severe underweight decreased from based PD/Hearth nutrition intervention self efficacy22 and thus greater inclusion
10.0% at baseline to 1.3% at follow- in the rural highlands of Ecuador, the of the nutrient-dense foods promoted
up. In the comparison group, the prev- researchers found that over 6 months, in the intervention. Overall calcium,
alence of underweight increased from mothers were able to reduce the risk of iron, and zinc content of the diet re-
23.4% at baseline to 25.9% at follow- underweight and severe underweight mained low, as reflected by low con-
up and the prevalence of severe for their children and improve the sumption of animal source foods, which
(WAZ < –3) underweight increased diet and weight of their infants and have been shown to have positive ef-
from 5.1% at baseline to 6.2% at young children using local foods and fects on length in toddlers.23 Although,
follow-up. The intervention did not resources, although intake of minerals self-efficacy for the preparation and
have a crude significant effect on being remained low. feeding of many of the intervention
6 Roche et al Journal of Nutrition Education and Behavior  Volume -, Number -, 2016

of donated rice, beans, and oil through

100 behavior change communication and
% Consumed food in previous 2 weeks

90 potentially enabled it by liberating

80 household resources.24
Here, the researchers did not see im-
70 provements in length, only weight. This
60 follows the original intended outcome
50 of the PD/Hearth nutrition education
40 intervention, which was designed to
rehabilitate underweight children.8
30 The focus here was on dietary diversity
20 and the timely introduction of comple-
10 mentary foods, rather than on increasing
0 overall energy intake directly, but because
overweight and obesity are of increasing
concern globally, the potential nega-
tive consequences later in life as a result
of early rapid weight gain without
linear growth merit consideration.25,26
Interventions resulting in both linear
growth and weight gain are needed in
Ecuador and many developing countries.27
Intervenon n=80 Comparison n= 184
In Peru, a health facility–based nutrition
education effort in a food-secure area
Figure 2. Percentage of intervention and comparison infants and young children aged showed benefit in length and weight
6–30 months (n ¼ 264) at 6-month follow-up who consumed promoted foods in the with an intervention effect of 0.49 LAZ
previous 2 weeks (September to October, 2009). *P < .05; **P < .001: Significance is and 0.34 WAZ28; however, this prom-
based on the difference in the proportion of children consuming foods in the interven- ising intervention was delivered through
tion and comparison groups. Fisher’s exact test was used to compare the proportions health centers, which are not univer-
of children consuming foods in the Food Frequency Questionnaire and was confirmed sally accessible in rural Ecuador.2 Stunt-
with binary logistic regression with adjustment for age, sex, and socioeconomic status. ing prevention may be more complex
and may require additional interven-
recipes may have increased, it is likely in Guatemala, which included a strong tions in pregnancy and even precon-
that household availability and afford- behavior change communication compo- ceptionally.29
ability were barriers to accessing animal nent, was able to increase consumption
source foods. A food assistance inter- of local animal source foods and plants;
vention with indigenous communities in addition, it increased consumption
IMPLICATIONS FOR
RESEARCH AND
PRACTICE
Table 3. Predictors of Change in Weight-for-Age z-Scores (WAZ) in Infants and
Young Children Aged 6–30 Mo (n ¼ 249) for Intervention and In this study, mothers showed the
Comparison Communities in Ecuadorian Andes at 6-Mo Follow-up active role they can have in improving
(September to October, 2009) children's nutrition at the community
level.ThePD/Hearthinterventiondescribed
Variables b* (95% Confidence Interval) P here was effective in enabling mothers
to improve infant's and young chil-
Dependent variable
dren's feeding practices and reduce un-
Change/DWAZ (n ¼ 249)
derweight over 6 months; yet program
Independent variables
evaluations of longer-term benefits at
Participation in intervention (yes) 0.17 (0.01 to 0.33) .04
1 year and beyond would be valuable
Age, mo 0.01 (–0.01 to 0.01) .80
contributions to implementation research,
Sex, female 0.03 (–0.11 to 0.17) .66
as would additional randomized studies;
SES status (score)a –0.09 (–0.19 to 0.02) .12
these were limitations of the current
Mother’s education, y –0.02 (–0.04 to 0.01) .17
study. Understanding the social bene-
Diarrhea at baseline (yes) 0.18 (0.02 to 0.34) .03
fits and the value of peer support
WAZ at baseline –0.22 (–0.29 to –0.16) <.001
groups for other interventions also
SES indicates socioeconomic status; WAZ, weight-for-age z-scores. warrants investigation. Given the
a
SES composite score includes walls, floors, power source, and water access; persistent challenges in meeting mi-
*Analyses also control for potential influence of clustering with 14 dummy variables cronutrient intakes in this population
for community of residence (not shown). Significance at P < .05. Statistical test and many others, additional interven-
was multiple linear regression: R ¼ 0.518; multivariate coefficient ¼ 0.269. tion activities are warranted; yet the
Journal of Nutrition Education and Behavior  Volume -, Number -, 2016
Table 4. Predictors of Underweight in Infants and Young Children Aged 6–30 Mo
(n ¼ 249) in Intervention and Comparison Communities at 6-Mo Follow-
up in Ecuadorian Andes (September to October, 2009)
Odds Ratio* (95%
Variables Confidence Interval) P Vitamin A and Iron Deficiencies: A Review
Dependent variable
Underweight at follow-up (WAZ < –2) (n ¼ 249)
Independent variables
Participation in intervention (yes) 0.36 (0.13–0.96) .04
Age, mo 0.94 (0.88–1.01) .09
Sex, female 0.94 (0.42–2.1) .89
SES (score)a 1.6 (0.83–3.0) .17
Mother’s education, y 1.03 (0.87–1.22) .71
Use of bottle to consume liquids (yes) 1.44 (0.58–3.56) .43
Latrine ownership (yes) 1.92 (0.78–4.72) .17
Diarrhea at baseline (yes) 0.29 (0.10–0.86) .03
WAZ at baseline 0.08 (0.04–0.16) <.001
SES indicates socioeconomic status; WAZ, weight-for-age z-score.
a
SES composite score includes walls, floors, power source, and water access;
*Analyses also control for potential influence of clustering with 14 dummy variables
for community of residence (not shown); Significance at P < .05. Statistical test
was logistical regression: Cox and Snell multivariate coefficient ¼ 0.395.
mother groups and peer support offer a
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CONFLICT OF INTEREST
Julieta Sarsoza works for World Vision
Ecuador. The rest of the authors have
not stated conflicts of interest.