The Healthy Mother Healthy Baby Toolkit: utilizing an innovative feeding tool to improve nutritional outcomes for women and children Restricted; Files Only
Ekwueme, Moses (Summer 2025)
Abstract
Objective: Despite the widespread consensus on the importance of adequate nutrition for children 6-23 months, suboptimal complementary feeding practices remain a global health challenge. The Healthy Mother Healthy Baby Toolkit was designed to influence maternal and complementary feeding practices. This dissertation aimed to provide evidence on the feeding toolkit's acceptability, describe the facilitators and barriers to integrating it into nutrition programs, and generate evidence of the toolkit’s utility for improving feeding practices from early-stage implementation data.
Methods: We used data from 14 countries located in the Middle East and North Africa Region (MENAR), East and South African Region (ESAR), and the West and Central Africa Region (WCAR). We conducted user testing in Ethiopia using the Trials of Improved Practices (TIPs) methodology to assess the acceptability and feasibility of the toolkit on a sample of 45 women: 15 pregnant women, 15 lactating mothers, and 15 women with children between 6 and 12 months of age. This User Testing was designed to gather data from the above sample of women on the utility of the toolkit; They were provided with the toolkit, counseled on how to utilize it for improving dietary intake in the first thousand days, and data on its use and feedback on the toolkit was gathered from participants over 4 weeks at the household settings. Across the 13 UNICEF-supported countries that integrated the toolkit into nutrition programs, we utilized a combination of focused group discussions, key informant interviews, desk reviews, and a cluster-randomized trial to capture the perceived effect of the toolkit on feeding practices and the facilitators and barriers that influenced integration efforts.
Results: In Aim 1, we found that the feeding toolkit was widely accepted by participants in the 4-week long user testing. Pregnant and breastfeeding women self-reported improvements in meal frequency, dietary diversity, and breastmilk production, while those providing complementary feeding reported improvements in animal-sourced food consumption, meal consistency, portion sizes, and dietary diversity for their children. In Aim 2, we utilized the Consolidated Framework for Implementation Research to identify five barriers and seven facilitators that influenced the integration of the feeding toolkit into already-existing nutrition programs in 13 countries. We also documented the integration programs that were effectively utilized to integrate the toolkit across all countries. Findings from this aim provided actionable insights into implementation factors that impact the integration of the feeding toolkit in diverse country contexts. In Aim 3, we found that when paired with culturally sensitive nutrition counseling and integrated into existing nutrition programs, the feeding toolkit led to self-reported improvements in dietary diversity, feeding frequency, hygienic practices, and caregiver-child interaction.
Conclusion: We demonstrated that the integration of a low-cost feeding toolkit into existing nutrition programs could improve complementary feeding practices for children 6-23 months. Addressing the implementation barriers and leveraging the facilitators could help ensure the successful integration of the toolkit and the maximization of its effectiveness.
Table of Contents
1. Chapter 1 - Introduction. 13
1.1. Research Aims. 15
2. Chapter 2 - Background. 17
2.1. The Global Burden of Maternal and Child Malnutrition. 17
2.1.1. Malnutrition in the First 1,000 Days. 17
2.1.2. Causes of maternal and child undernutrition. 18
2.2. Nutritional requirements of pregnancy and lactation. 19
2.2.1. Prevalence of maternal malnutrition. 21
2.2.2. Consequences of maternal undernutrition. 23
2.3. Prevalence of child undernutrition. 24
2.4. Recommendation for complementary feeding for children 6-23 months. 26
2.5. Determinants of complementary feeding practices for children 6-23 months. 29
2.5.1. Adequate foods. 29
2.5.2. Adequate services. 30
2.5.3. Adequate practices. 31
2.6. Current approaches to improve complementary feeding practices. 32
2.6.1. Platforms utilized for delivering nutrition counseling. 33
2.6.2. Effectiveness of counseling interventions on nutrition and health outcomes. 34
2.6.3. Social and behavior change communication in nutrition counseling: the role of behavioral cues. 36
2.7. The HMHBT as a cue to action. 38
2.8. Gaps in knowledge of the feeding toolkit's effectiveness. 40
2.9. Implementation science: Bridging the gap between evidence and action in nutrition. 42
2.9.1. Overview of implementation science. 42
2.9.2 Key implementation science frameworks and their application in nutrition. 43
3. Chapter 3 – Data Sources. 57
3.1. Study settings. 57
3.2. Data collection and management 58
3.2.1. User testing using Trials of Improved Practices (TIPs) in Amhara, Ethiopia (Objective 1) 58
3.2.2. Phase 1: An initial documentation of the use of the bowl and spoon in all 13 countries (Objective 2) 60
3.2.3. Phase 2: An in-depth documentation of improvements in feeding practices and development outcomes in three countries that have distinct contexts (Objective 3) 61
3.3. Statistical methods and data analysis. 64
4. Chapter 4 - Testing the feasibility and acceptability of a feeding toolkit in improving maternal and child feeding practices in Ethiopia’s Amhara region. 71
4.0 Abstract 72
4.1. Introduction. 73
4.2. Methods. 74
4.2.1. Study design and setting. 74
4.2.2. Data collection. 75
4.2.3. Data management and analysis. 76
4.3. Results. 77
4.3.1. pregnant women and lactating women: Nutritional practices at baseline. 77
4.3.2. Use of the bowl and endline nutritional practices. 79
4.3.3. Bowl and spoon use for complementary feeding. 82
4.3.4. Addressing maternal and child nutritional practices: insights from health workers. 85
4.3.5. Feedback on the bowl and spoon and distribution platforms. 86
4.4. Discussion. 88
4.5. Conclusion. 92
5. Chapter 5 - Barriers and facilitators to integrating UNICEF's complementary feeding toolkit into nutrition programs: a multi-country, early-stage analysis using the Consolidated Framework for Implementation Research (CFIR) 99
5.0 Abstract 100
5.1. Introduction. 101
5.2. Methods. 102
5.2.1. Study design and conceptual framework. 103
5.2.2. Study setting. 104
5.2.3. Study sample. 105
5.2.4. Data collection. 105
5.2.5. Data analysis. 106
5.3. Results. 107
5.3.1 Domain 1: Intervention characteristics. 107
5.3.2. Domain 2: Outer setting. 109
5.3.3. Domain 3: Inner setting. 111
5.3.4. Domain 4: Characteristics of the individual 114
5.3.5. Domain 5: Implementation process. 116
5.4. Discussion. 118
5.5 Conclusion. 123
6. Chapter 6 - Assessing the utility of the UNICEF complementary feeding toolkit for improving child feeding practices in Burkina Faso, Uganda, and Malawi: a mixed-method study. 132
6.0 Abstract 133
6.1. Introduction. 134
6.2. Methods. 136
6.2.1. Study design. 136
6.2.2. Study settings. 137
6.2.3. Study sample. 138
6.2.4. Data collection. 139
6.2.5. Statistical analysis. 140
6.3. Results. 141
6.3.1. Theme 1: Acceptability, feasibility, and sociocultural dynamics affecting the use of the toolkit for complementary feeding practices. 141
6.3.2. Theme 2: Perceived improvements in complementary feeding practices. 143
6.3.3. Theme 3: Feedback on the feeding toolkit 149
6.4. Discussion. 149
6.5. Conclusion. 154
7. Chapter 7 - Expanded discussion. 163
7.1 Summary of findings. 163
7.2. Limitations. 165
7.2.1. Reliance on subjective data sources. 165
7.2.2. Short-term evaluation window.. 166
7.2.3. Context-specific factors affect generalizability. 167
7.3. Study strengths and innovation. 168
7.4. Implications of our findings. 170
7.5. Conclusion. 175
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