Effect of Integrated Agricultural and Health Based Interventions on the Nutritional Status of Under Five Children in the Southern Part of Bangladesh

Abstract

Background: Combating malnutrition in all of its forms has become a global health concern. Introducing nutrition-sensitive interventions that incorporate agriculture and health-based approaches could help to achieve food and nutrition security, improve diets, and eventually improve nutritional status, thereby reaching the nutrition-related Sustainable Development Goals. As previous literature revealed a lack of conclusive evidence on the effect of integrated intervention, the purpose of the study was to capture evidence of both short- and long-term effects of the integrated intervention on under-five children participating in an agriculture and health-based intervention program. Objective: This study was an evaluation of the Integrated Agriculture and Health- Based Interventions (IAHBI) project for improved food and nutrition security in selected districts of southern Bangladesh. The intervention project was implemented by the joint initiative of the government with the technical support of the Food and Agriculture Organization (FAO) and the United Nations Children‘s Fund (UNICEF).The overall objective of the present study was to evaluate the effect of agriculture and health-based intervention program on nutritional status among under-5 children, as well as the post implementation long-term/ sustained effects of the IAHBI project completion using the RE-AIM framework. The specific objectives of the present study were a) to assess the reach of the project inputs in the target population; b) to describe the effectiveness of intervention activities (nutrition and other intervention outcomes and IYCF indicators); c) To investigate experiences of participants in adopting project inputs; d) to consider implementation challenges and successes; and e) to explore the maintenance or sustainability of intervention activities post project implementation. Methodology: The present study was a cross-sectional mixed-method approach which is divided into Quantitative and Qualitative phase. Quantitative: In the secondary analysis, data from the (BRAC Institute of Global Health (BIGH), 2013) and (Institute of Nutrition and Food Science, 2015) were analyzed for the assessment of the effect of intervention on the nutritional status of under-five children using Stata and Anthro 2007 software. x Qualitative: Initially, a review of the study "Mainstreaming Nutrition into Agricultural Extension," referred to as "Follow up I" was carried out as part of this PhD research work. Furthermore, in 2021, the researcher performed another primary study titled 'Follow up II,' which focused on the long-term impact of the project intervention using qualitative research. focus group discussions (FGD), key informant interviews (KII), and in-depth interviews (IDI) were used to collect data for ‗Follow up II‘ study in Shafipur and Batamara union of Barishal district. In addition to that, Internal reports, Terminal reports and other supportive secondary documents were also taken into consideration. The REAIM framework (Reach, Effectiveness, Adoption, Implementation, Maintenance) (Glasgow et al., 1999) (Glasgow et al., 2001) was used to evaluate the long-term effect of the IAHBI intervention program.(Glasgow et al., 1999) (Glasgow et al., 2001). Under the RE-AIM framework for reach domain internal report, FAO; for effectiveness domain secondary quantitative analysis of baseline and endline study; for adoption domain follow up I study, supported by KII findings from follow up II; for implementation domain internal report, FAO and for maintenance Follow up II study as well as comparison across three timelines (Endline-2015, Follow-up I- 2016, Follow-up II-2021) were considered. Results: Based on RE-AIM framework, ‗Reach domain‟ revealed that the project reached 31,092 beneficiaries out of 50,000 due to fund constraints. In the ‗Effectiveness domain‟, secondary analysis of quantitative findings revealed that the prevalence of stunting (34.3% to 33.5%) and wasting (11.5% to 9.3%) were reduced in percentage points, while underweight (30.7% to 23.9%) was significantly reduced from baseline to endline study. According to the logistic regression model, age, educational qualification, and wealth quintile were significantly correlated with underweight. In addition, good practices in horticulture, hygiene, and cooking interventions had significantly improved at the endline compared to the baseline. . In the „Adoption domain‟, at individual level illustrates beneficiaries‘ adoption of the intervention immediately after (almost eight months) the project completion. it was found that most of the beneficiaries have adopted nutritional knowledge regarding balanced diets, diversified foods, IYCF practices, dietary diversity, hygiene practices we well as knowledge about food safety and preservation. They have also adopted pit xi cultivation methods and eco-friendly fertilizers, environment friendly poultry shed and aquaculture cultivation procedure. In contrast, the 'Adoption' domain at the organization level showed that Bangladesh government has well adopted multi-sectoral collaboration between different ministries, which promotes nutrition security substantially. Most were found to sustain knowledge about nutrition education under the „Maintenance/sustainability domain‟. Aside from providing their children with fresh food, those who are engaged in horticulture gardening, poultry rearing, and livestock rearing are also earning money. Those who could not afford to sustain the incentives due to poverty had difficulty doing so. The majority of the participants revealed that the cooking tools they received as part of the intervention are underutilized. The majority are still engaged in income-generating activities and confident that the community has accepted them., but they still lack decision-making capacity. Unfortunately, there were no sustained multi-sectoral linkages between the ministries of agriculture, livestock, and fisheries to provide services, even to the beneficiaries. The comparison study result showed that training on food-based nutrition education and providing incentives were helpful to improve food security, safe and healthy cooking practices, and women‘s empowerment. Women are still practicing incomegenerating activities and are empowered with social status and honor in society. But regarding decision-making capacity, only female-headed households and women with substantial income are capable of making decisions. However, home-based facilities for the utilization and preservation of surplus food production and inter-sectoral collaboration between implementers and ministries of government were not well maintained. Conclusion: Short-term results of the integrated agriculture and health-based intervention, under ‗effective‘ domain showed a significant reduction in underweight among children under five. Moreover, good agricultural practices, hygiene practices, and cooking techniques were significantly improved in the endline study compared to the baseline study. Integrated intervention programs are sustainable within a traditional food system when local capacity and household capacity are in place to absorb interventions and sustain their adoptionAn integrated multi-sectoral approach was adopted in the national action plan. The multi-sectoral collaboration that was xii intended to improve the nutritional situation in the project area was not maintained once the project was over. There is a need for further research to determine how to overcome the barriers identified in the present study to improve the sustainability of agriculture and health interventions.