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Journal of Human Nutrition & Food Science

Cite this article: Garg A, Chadha R (2016) Community-Based Nutrition Counseling Improves Complementary Feeding Practices and Growth of Infants (6-12 Months) in Rural Uttar Pradesh, India. J Hum Nutr Food Sci 4(5): 1099.

*Corresponding authorAashima Garg, Department of Food and Nutrition, University of Delhi, K-I-8 Kavinagar, Ghaziabad, Uttar Pradesh-201002, India, Tel: +919910063447; Email:

Submitted: 16 July 2016

Accepted: 23 November 2016

Published: 08 December 2016

ISSN: 2333-6706

Copyright© 2016 Garg et al.

OPEN ACCESS

Research Article

Community-Based Nutrition Counseling Improves Complementary Feeding Practices and Growth of Infants (6-12 Months) in Rural Uttar Pradesh, IndiaAashima Garg* and Ravinder ChadhaDepartment of Food and Nutrition, University of Delhi, India

Abstract

Background: Inappropriate Complementary Feeding (CF) practices together with high levels of stunting remain a major public health challenge in rural poor households of India.

Objective: To assess the effectiveness of Community-Based Nutrition Counseling (CBNC) approach to improve CF practices and growth of infants (6-12 months).

Methods: Quasi-experimental study set in six matched villages of rural Uttar Pradesh, India, had three randomized groups-intervention (IG), comparison-I (CG-I: visitation) and comparison-II (CG-II: true control). Study subject included mother-infant pairs enrolled at infant’s age 4 months and followed till 12 months of age in IG (n 62), CG-I (n 63) and CG-II (n 64).All groups received routine Integrated Child Development Services under National Government program; IG in addition received CBNC. CBNC included counseling on CF by trained community counselors in conjunction with already existing village level service providers using multiple channels of communication for delivery of standardized messages. Final impact of intervention was assessed through the end-line data collection at infants’ age 12 months in IG vis-a-vis CG- I and CG-II. Outcomes assessed at end-line included improved CF practices using Complementary Feeding Index (CFI) and improved growth of infant sw.r.t attained weight, length, Body Mass Index (BMI) and growth velocity.

Results: At 12 months, quality of CF, measured by CFI scores was significantly higher in IG as compared to CG I and II (97% v/s 0 and 2%, p <0.05); IG infants were significantly heavier and longer as compared to CG I and II (p <0.001); fewer IG infants as compared to CG I and II infants were underweight (nil v/s 36.5%, 53%), stunted (4.8% v/s 67%, 65%) and wasted (nil v/s 6.3%, 12.5%).

Conclusion: Study provides evidence on CBNC approach, which improved CF practices and growth of infants in rural Indian settings and can be tested in other country settings.

Keywords•Complementary feeding•Community-based nutrition counseling•Infants•Uttar Pradesh•India

ABBREVIATIONSCBNC: Community Based Nutrition Counseling; CF:

Complementary Feeding; IG: Intervention Group; CG: Control Group; ICDS: Integrated Child Development Services; CC: Community Counselors; IPC: Inter-Personal Counseling; BCC: Behaviour Change Communication

INTRODUCTIONInappropriate Complementary Feeding (CF) practices

together with high levels of stunting remain a major public health challenge in rural poor households of India [1-3]. Limited evidence exists that nutrition education and counseling delivered by trained community-based volunteers or health workers can

significantly improve CF practices adopted by the mothers [4-6] and growth of their infants in different settings [7-9] In India, very few studies demonstrate the effectiveness of educational interventions delivered either through trained community health workers or through health workers from the existing government system on improved CF practices and growth of infant [9-11]

In India, nutrition services are primarily delivered to the community through the National Flagship programme namely Integrated Child Development Services (ICDS1). In addition, other community structures may exist at the village level in the form

1ICDS- Largest child development service delivery programme of Government of India that provides infants, young children and mother’s supplementary nutri-tion, health care and pre-school.


Garg et al. (2016)Email:

J Hum Nutr Food Sci 4(5): 1099 (2016) 2/13

of local government, Community-Based Organizations, religious leaders, local village doctors, mother’s groups, teachers and motivated agents of community. The present study tests a model approach of delivering counseling for improving CF practices, in rural settings of Uttar Pradesh state, India. The approach involved catalyzing the existing community structures at village level for effective service delivery in concurrence with enhanced demand for nutrition and health services by the community.

The objective of the study is twofold: (i) to assess the effectiveness of ‘Community-Based Nutrition Counseling (CBNC) approach’ in improving CF practices and growth of infants aged 6-12 months belonging to rural households in Uttar Pradesh, India. (ii) to inform the design and implementation of the programmes for delivery of quality CF counseling in rural India and other similar settings.

MATERIALS AND METHODSStudy settings: The study was conducted in six purposively

selected, matched villages from 3 ICDS blocks of district Ghaziabad, of Uttar Pradesh state in India. After the formative phase, the selected blocks were randomly assigned to three study groups namely intervention (IG), comparison-I (CG-I) and comparison-II (CG-II).

Participants and sample size: The study participants were mother-infant pairs enrolled at infant’s age 4 months and followed till 12 months of age. Sample size for the study (n=180) was calculated using a formula based [12] on achieving at least 50 percentage point increase in the timely CF rates of the infants of the IG, assuming high attrition rates ( >20%) during the study follow-up and for higher precision and accuracy of the study results. A sample size of 60 per group was estimated with α = 0.05, design effect of 2 and 90% power. At the beginning of intervention (infants’ age 4 months), a total of 226 mother-infant pairs (IG=73, CG-I=78; CG-II-75) were enrolled in the study for follow-up, of which 189 mother-infant pairs (IG=62, CG-I=63; CG-II=64) could be followed up until the 12 months age, which formed the final sample size for the study.

Study design: The research was a quasi-experimental design, with one intervention and two comparison groups. The rationale of having two comparison groups was to increase strength of the research design by taking care of the Hawthorne effect2 due to parallel data collection contacts in comparison-I group villages. Thus, the study group comprised:

(1) Comparison-I group (CG-I): Mothers and infants in this group received routine ICDS services, which were operating across all the study groups. Under the routine ICDS service delivery the infants, young children and their mothers receive the weekly supplementary nutrition, routine immunization, basic health care services and monthly weighing of children. This group was the visitation group where the parallel data collection was intended at comparative analysis with the intervention group. No additional information related to infant feeding and child-care practices was provided by the investigator to the mothers or family members during the visits to target households.2Hawthorne effect is a phenomenon in which subjects improve an aspect of their behavior being measured simply in response to the fact that they are being studied, not in response to any particular experimental manipulation.

(2) Comparison-II group (CG-II): Like CG-I, mothers and infants in this group also received routine ICDS services. This group was treated as the true comparison group, where data was collected at baseline (at 4 months), at 6 months and end line (at 12 months of age). No additional contacts were made by the investigator in these villages during the study period.

(3) Intervention Group (IG): Community-Based Nutrition Counseling (CBNC) approach was implemented in the villages of this group. Mothers and infants in IG received strengthened ICDS service delivery under the CBNC. CBNC can be described as nutritional counseling delivered through identified and trained community counselors (CCs) in conjunction with already existing service providers (Anganwadi Workers (AWWs)3, village level health worker, and local village doctors) using multiple channels of communication and delivery platforms’. CBNC involved delivering strengthened ICDS service delivery which in addition to routine ICDS service delivery included delivery of counseling on age-appropriate infant feeding by CC and existing service providers during the growth monitoring and promotion sessions, mother’s group counseling sessions, home visit counseling, immunization routines, religious gatherings and local village doctors’ consultation.

Figure (1) presents the four stages of the study with details on intervention development, intervention, impact assessment and data analysis below.

Intervention development: Formative research was conducted to study the prevailing CF practices, growth and morbidity pattern of infants aged 6-12 months and understand the gaps, barriers and facilitators of the CF practices in the study villages. Data was collected using quantitative and qualitative methods using household questionnaires, 24-hour recall, food frequency questionnaire, observations and focus group discussions. The findings of formative phase guided the designing of a context specific and need based intervention. The methodology and results of the formative phase have been published elsewhere [13,14].

As a next step, context-specific interventions were identified. Intervention model and key intervention messages for counseling on age-appropriate CF and breastfeeding practices were developed. Participatory micro-planning4 at village and Anganwadi Center (AWC)5 level were carried out to develop AWC level micro-plans. An active women from each AWC coverage area was identified and trained as CC to serve as a link between the service providers and communities. Community mobilization activities focused on building a supportive and enabling environment for the CCs were conducted. CF counseling guide (Pictorial flip book) and training modules targeted at CCs, AWWs, 3AWW is an honorary outreach worker who runs AWC.

4Micro-planning is a participatory process of assessing, prioritizing and plan-ning a needs based programme. Process involves local community and results in development of a micro plan which guides programme implementation and monitoring.

5AWC is a childcare centre, located within the village over a population of 1,000. It is the focal point for grassroots-level service-delivery of six key services-supplementary nutrition, non-formal preschool education, immunization, health check-up, referral services, and nutrition education, including growth monitoring promotion.




- 1 - - 1 -

Study Site: 6 villages from 3 Blocks (2 villages from each block), District Ghaziabad, Western Uttar Pradesh. Formative Phase (n=151): Study existing complementary feeding practices, weight, length & morbidity status of infants (6-12 months).

Intervention Group 1 Block (2 villages)

Comparison Group-II 1 Block (2 villages)

Comparison Group-I 1 Block (2 villages)

Development of a Community-Based Nutrition Counseling (CBNC) approach

1. Understanding and identifying context-speci�ic strategies for intervention

2. Microplanning at village & AWC level 3. Identi�ication of Community Counselors (CCs) 4. Development of complementary feeding counseling

guide and training module 5. Developing community-based monitoring tools and

training the CCs in monitoring behaviour change using these tools

6. Capacity building of AWWs and CCs

Implementation and monitoring of CBNC approach

Intervention Group (n =62) Target: Infants aged 4 months

followed till they were 12 months Intervention Group Implementation of CBNC Approach Strengthened ICDS Service Delivery • Capacity Building of AWWs & CCs • Counseling-weekly home visits

by CCs & monthly Group counseling/food demonstration sessions by CCs & AWWs

• Synergy with village local bodies Data collection visits: 1. Baseline- At the time of enrollment (4 months), 2. At 6 months and 3. End line-at infants’ age 12 months. 4. Morbidity status: Monthly 5. Dietary assessment (24-hour recall & semi quantitative FFQ): Monthly 6. Weight & Length gain: Bimonthly 7. CF Indicators: Monthly by CCs and at 6, 9 & 12 months of age

Comparison Group-I (n =63)

Target: Infants aged 4 months followed till they were 12 months Visitation Group No intervention

Routine ICDS Service Delivery • No additional intervention

and information provided Data collection visits: 1. Baseline- At the time of enrollment (4 months), 2. At 6 months and 3. End line-at infants’ age 12 months. 4. Morbidity status: Bimonthly 5. Dietary assessment (24-hour recall & semi quantitative FFQ): At 6, 9 & 12 months of age 6. Weight & Length gain: Bimonthly 7. CF Indicators: At 6, 9 & 12 months of age

Comparison Group- II

(n=64) Target: Infants aged 4 months

followed till they were12 months Control group No Intervention

Routine ICDS Service Delivery • No additional intervention

and information provided Data collection visits- 1. Baseline- At the time of enrollment (4 months), 2. At 6 months and 3. End line-at infants’ age 12 months.

Impact of Intervention: 1. Assess the impact in intervention group in terms of i) improved complementary feeding practices, ii) morbidity status (diarrhea, fever, cough & ARI prevalence) iii) growth of infants

Stage-1

Random Allocation

Stage-2

Stage-3

Stage-4

Comparison Group 2 Blocks (4 villages)

Random Allocation

Note: AWW- Anganwadi Workers (Frontline Functionaries of ICDS); AWC- Anganwadi Centre (Service delivery Point for ICDS); CC-Community Counselor; CBO-Community Based Organization; FFQ- Food Frequency Questionnaire; CF-Complementary Feeding; CBNC-Community-Based Nutrition Counseling approach; ARI-Acute Respiratory Infection

Figure 1 Study Design. Note: AWW- Anganwadi Workers (Frontline Functionaries of ICDS); AWC- Anganwadi Centre (Service delivery Point for ICDS); CC-Community Counselor; CBO-Community Based Organization; FFQ- Food Frequency Questionnaire; CF-Complementary Feeding; CBNC-Community-Based Nutrition Counseling approach; ARI-Acute Respiratory Infection




Box-1

Key Complementary Feeding Messages delivered to the mothers and caretakers of infants through CBNC Approach in the Intervention Villages

(Messages were developed in local language)

Breast feeding- Continue to breastfeed your child in addition to feeding them with recommended complementary foods1

Complementary Feeding- Feed your child foods modified from the family pot i.e. the recommended complementary feeding foods. At 6 months start with 0.5 katori of recommended complementary foods 3 times (breast-fed child) or 5 times (non-breast fed child). Gradually increase the quantity to 1 katori by 9 months of age.

Responsive feeding- Make child sit in your lap and feed child yourself. Maintain eye contact with your child and recite stories and songs while feeding your child. Feed the child with a separate katori.

Hygiene- Wash child’s and own hands with soap before a meal. Feed the child in clean utensils. Store the cooked food by covering and storing at a higher place. Use glass with a handle to take out water from the water storage pot.

Feeding a Sick Child- Breastfeed the sick child more frequently. Continue feeding all foods in recommended amounts when sick. Feed child an extra meal during the catch-up phase (2 weeks following the illness).

1 Recommended Complementary foods to be given: 1) undiluted sweetened milk with mashed roti/rice/biscuit/bread; 2) thick dal with added oil with mashed roti/rice/bread or khichri with added oil. Add cooked vegetables (green leafy, yellow or any other vegetable) to the meal; 3) sevian or dalia or halwa or kheer prepared in milk or other milk-based preparations; 4) mashed potatoes or sweet potato or potato subzi without spices; 5) banana or biscuits or mango or papaya or other seasonal fruit as snacks

2 Katori is 150 mL bowl.

Note: Key Messages were developed by adapting and contextualizing the WHO(19) recommendations.

ANM6 and local village doctors were developed. Community-based monitoring tools to monitor the intervention and track the behavior change at community level were developed. Capacity building sessions for AWWs, ANMs and CCs focused on delivery of intervention specific messages using inter-personal counseling (IPC) skills were conducted. Special focus was given on applying the principles of inter personal communication, negotiation and convincing the mothers to adopt the recommended feeding behaviors using the pictorial flipbook and food demonstration sessions. Box 1 presents the key intervention messages that were delivered through CBNC approach.

The intervention

The intervention was implemented in the IG villages with parallel data collection in CG-I as per the study design where routine ICDS services were provided (Figure 1).

In the IG villages, the target families received a minimum of one nutrition counseling session per week at household level by the CC. In cases where infant was sick, frequency of counseling session increased to 2-3 times in a week. Weekly counseling sessions at the household level by CC included observation and follow-up on the key messages of last counseling session, explaining the benefits of recommended CF behaviors, use of pictorial flipbook illustrating the recommended behaviors, ‘checking’ questions to ensure mothers’ correct understanding, and praising for behavioral intention. In each counseling visit, the CCs observed, demonstrated and supported the infant’s

6ANM is the village level health worker responsible for delivering essential health care services to women and children in a cluster of villages.

caregivers on what, how much and how to feed their infant using pictorial flip book and food demonstration technique with special emphasis on following hygiene behaviors. Food demonstration sessions at household and community level were organized with a dual objective of demonstrating age-appropriate consistency, quality and quantity of CF together with building the confidence of caretakers to feed their young child using responsive feeding principles.

Each CC while supporting 20-30 households in their neighborhood, worked in close coordination with their respective AWW and ANM. With their role in household level counseling and community mobilization, CC complemented the work of AWWs and ANMs by mobilizing target families to AWC or health sub-centers for routine outreach services and thus minimizing any overlap in their roles.

The approach also focused on strengthening and catalyzing the existing Government health and nutrition (ICDS and Health Department) service delivery systems by establishing synergies within local bodies-village level Local Governance (Panchayati Raj Institution), women’s groups (mahilamandals), religious leaders, local village doctors and local Community Based Organization (CBO) in the village7. Kitchen garden in the target houses was promoted with an objective of improved dietary diversity in child’s and family’ diet. Orienting and motivating the families on use of vegetables from kitchen garden in the infant’s diet was

7CBO was a starter organization of the village, registered few months before the start of intervention and comprised of a small group of active youth members who were involved in supporting the regular campaigns of health and ICDS depart-ments in the village.




Table 1: Socio-demographic comparisons of the three study groups’ characteristics.Socio-demographic Characteristic

%χ2

φI πC-I λC-II TotalFamily Type, Religion and CasteFamily type Joint 30.6 55.6 59.4 48.7

12.194*Nuclear 69.3 44.4 40.6 51.3Family Size: Mean ±SD 6.95 ± 3.30 8.09 ± 3.26 8.65 ± 3.63 7.91 ± 3.46 4.086 a *ReligionHindu 43.5 55.6 60.9 53.4

3.997Muslim 56.4 44.4 39.1 46.6CasteGeneral 9.7 4.8 6.2 6.9

7.948#Backward Classes 9.7 22.2 29.7 20.6Schedule Castes 24.2 28.6 26.6 26.5Alpsankhyak (Muslim castes) 56.4 44.4 37.5 45.5Maternal CharacteristicsAge (years)≤ 19 1.6 0.0 0.0 0.5

2.160#20-29 72.6 82.5 81.2 78.830-39 24.2 17.5 15.6 19.1≥ 40 1.6 0.0 3.2 1.6Educational Status

11.495#

Illiterate 33.9 44.4 39.1 39.1Literate (can read & write) 32.3 9.5 17.2 19.9Primary (up to 5th standard) 11.3 19.0 12.5 14.3Secondary ( up to 8th standard) 12.9 11.1 18.7 14.3High School (up to 10th standard) 6.4 9.5 9.4 8.5Intermediate (up to 12th standard) 0.0 4.8 1.6 2.1Graduate & above 3.2 1.6 1.6 2.1Parity: Mean ± SD 3.12 ± 2.23 3.00 ±1.82 2.95 ±1.70 3.05 ±1.92 0.315a

No. of living children1-2 45.2 49.2 51.6 48.7

1.196#

3-4 32.3 31.7 32.8 32.35-6 17.7 17.5 12.5 15.97-8 3.2 0.0 3.1 2.110-12 1.6 1.6 0.0 1.1Primary OccupationHousewife 91.9 95.3 93.7 93.6

2.170#Unskilled labourer 1.6 0.0 0.0 0.5Farm labourer 1.6 4.7 4.7 3.7Others-Shop owner, helper in shop, tailor 4.9 0.0 1.6 2.1φIntervention group (I): n=62, πComparison group-I (C-I): n=63, λComparison group-II (C-II): n=64. Data presents percentages, mean ± SD and Chi-square value. χ2- Pearson chi-square test, *Value significant at p<0.05. For all other variables, p value was > 0.05, #Yates’ Correction is applied as either at least one expected frequency is less than 1 or at least 20% of expected frequencies are less than 5, a ANOVA F value.

part of counseling sessions. Behavior Change Communication (BCC), a core intervention, included the use of locally developed CF pictorial flip book as a counseling tool, mothers’ competitions on preparing nutritious complementary foods, healthy baby shows and recipe demonstrations. These bi-monthly events were organized by AWW as per their AWC-wise micro plans with support of CC and ANM. These events created a platform for mothers to come together at AWC and collectively get involved in preparing local CF recipes, feeding the child using responsive feeding and hygiene principles, discussing problems in feeding their child, their achievements, good practices and progress on

child’s growth. Recognition and rewards for mothers’ efforts were part of all community events.

Reinforcement of the key intervention messages was done through consistent delivery of the messages at every possible opportunity using at the household and community level. Some of these opportunities included- painting the key messages on the walls of the villages (done every 3 months), polio campaign rallies (campaign happened every 2nd month), school rallies of children and teachers (every 3 months), pictorial posters with key messages pasted at public meeting places and at houses of




all the target infants, sick child contacts at local village doctor’s clinics and in religious gatherings through songs and speeches by religious leaders (at least once in every fortnight). Involvement of religious leaders from mosque and temple ensured that the key intervention messages were delivered at religious gatherings (which happened every week on Friday for Muslim community and any day for Hindu community) and ensured better acceptance of key behaviors especially by elders and the male members of the community.

Monitoring and Supportive supervision

The intervention was monitored by the government Health and ICDS supervisors with the support of local CBO and the investigator using the AWC-wise micro plans, study monitoring tools, monthly meetings, field monitoring and supportive supervision. CCs monitored the behavior change of their target households through a pictorial monitoring card using traffic signal colours (red-off track, green-on track and yellow-constrained). Monthly review was conducted by the ICDS supervisors with intervention stakeholders (Health supervisors, local bodies, CBO and local village doctors) using the AWC-wise micro-plans to assess the monthly performance, progress, achievements and barriers to achieving the program objectives in the village. Refresher capacity building sessions were organized on a monthly or bi-monthly basis (based on the assessment of CCs’ and AWWs’ performance). ICDS supervisors with the support of CBO members undertook regular message reinforcement and supportive supervision during the home visits and review meetings. Appreciation and recognition of the work done by CCs, AWWs, and village level health workers including the target mothers for practicing the recommended behavior was a regular (once in 3 months) feature of the intervention. Appreciation and recognition was shown through awarding certificates and trophies by the Government officials during community level events. Non-monetary incentives in the form of bags and badges to the CCs, AWWs and ANMs were used to raise their self-esteem and drive to perform better.

Assessing the Impact of Intervention

Final impact of intervention was assessed through the end-line data collection at infants’ age 12 months in IG vis-a-vis CG- I and CG-II for improved CF practices, morbidity status (diarrhoea, fever, cough and ARI prevalence and improved growth of infants.

The data in all 3-study groups was collected at household level using standardized pre-tested household level questionnaires at baseline (4 months), 6 months and end line (12 months). Each infant enrolled in the study was studied for 8 months duration i.e. from 4 months to 12 months of age.

The specific data collection points for various indicators in the 3 study groups have been shown in Figure 1. Weight (using Goltech digital weighing scale, 5 g sensitivity) and length (using locally manufactured infant meter, 0.1 cm sensitivity) were obtained at 4 month and thereafter every 2 months till 12 months of age in both IG and CG-I.

Data Management

Data management and statistical analyses were conducted

using the statistical software package Statistical Package for Social Sciences, version 13 (SPSS). Anthropometric data on weight and length of the infant according to the infant’s age (in completed months) was used to calculate z-scores for 4 indices: weight-for-age (WAZ), weight-for-length (WLZ), length-for-age (LAZ) and Body Mass Index (BMI)-for age (BAZ) as well as the prevalence of underweight, stunting, wasting and low BMI for age as per WHO[15] growth Standards. Bi-monthly and six monthly weight and length velocities were also calculated and compared with WHO16 growth velocity standards. The morbidity status of infants was studied for the prevalence of diarrhoea, fever, cough and ARI (cough with rapid breathing) in 15 days prior to the enquiry. The dietary data collected through 24-hour recall and past 7-days semi-quantitative Food Frequency Questionnaire (FFQ) [17] was scored using Complementary Feeding Index (CFI) for assessing the appropriateness of the CF practices in three study groups. CFI is a composite index (adapted from another index) [18] comprising of 6 scores on continued breastfeeding, avoiding bottle feeding, timely initiation of CF, dietary diversity (past 24 hours), meal frequency (past 24 hours), and food frequency (past 7 days). The scoring was done by assigning a score of ‘0’ for a potentially harmful practice and a score of ‘2’ for a positive practice in accordance with WHO [19]. Those practices in between these two were given a score of ‘1’. The individual scores were summed up to derive a composite CFI score, which was grouped into terciles to form three categories for defining the quality of CF practices: low ( ≤ 6), medium (7-16), and high (17-23).

Effect size was also calculated using Cohen’s formula [20] to quantify the magnitude of difference between intervention and comparison groups. Data on nutrient intake though collected and analyzed, but has not been included as part of this paper. Qualitative information on the facilitators and influencers of the access to and delivery of CF counseling was also collected as part of end-line data collection.

RESULTS AND DISCUSSIONFormative research confirmed sub-optimal breast-feeding

and complementary feeding practices. Of the total sample of 151 mother-infant pairs studied in the formative phase, 23% were in low CFI score and almost nil ( <1%) in high CFI score category, with majority achieving the medium CFI score-suggesting a gap in appropriate CF practices of infants. Complete results of formative phase have been published elsewhere [13,14].

As part of the study, a total of 189 mother-infant pairs were enrolled at 4 months and followed up to 12 months of age across the 3 study groups (IG=62; CG-I=63; CG-II=64). The socio-demographic characteristics of all infants at the time of enrollment were comparable (Table 1).

Breastfeeding Practices

The exclusive breastfeeding rates at 4 months of age were 9.7%, 9.5% and 7.8% in IG, CG-I and CG-II groups, respectively. Intervention helped in maintaining exclusive breastfeeding rates in IG to the same level of 9.7% as was at 4 months of age, with a considerable drop to 1.6% in both CG-I and CG-II groups at 6 months of age.




Complementary Feeding Practices

Almost all (97%) IG infants were introduced semisolid foods along with breastfeeding at the completion of 6 months of age v\s only 6% infants in both the CGs, who continued to receive diluted animal (buffalo) milk as their primary intake. As can be seen in table 2 the intervention was able to improve the quality of CF which was evident by significantly (p <0.01) higher proportion of IG infants as compared to CGs’ infants having optimal dietary diversity scores (≥ 3 and ≥ 4 food groups for 6-8 and 9-12 months, respectively) and higher mean number of food groups consumed between 6 to 12 months of age. At 12 months of age, mean food frequency score was significantly higher (p <0.01) for the IG as compared to both the CGs. Improvement in CFI scores was observed during the intervention and end-line, with almost all (97%) IG infants having high CFI scores v\s nil and 2% infants in CG-I and CG-II, respectively at 12 months of age. The mean CFI scores of IG were significantly higher (p <0.01) than CG-I and CG-II at 6, 9 and 12 months of age. High CFI scores of IG infants (19.5 ± 1.4 for IG vs 9.7 ± 3.3 and 10.9 ± 2.7 for CG-I and CG-II, respectively, at 12 months of age) show that IG mothers were following age-appropriate complementary feeding practices as promoted by CBNC approach.

Morbidity Prevalence

Table (3) shows that significant differences were observed at 8 months of age for diarrhoea, fever and ARI prevalence (p <0.05) and then at 10 months’ of age for diarrhoea, fever and cough (p <0.01) were observed. At 12 months of age, significantly higher prevalence (p <0.05) of diarrhea was observed in CG-II infants as compared to IG infants. The findings show that the intervention

was able to reduce the prevalence of these illnesses in IG infants especially at 10 and 12 months of age.

Growth of Infants

The attained growth of the infants in the study groups was assessed by studying the difference between IG and CGs on attained weight, length, BMI and growth velocity (Tables 4 and 5).

Attained weight

Table (4a) presenting mean weight of the infants, shows that at 12 months of age, on an average, the IG boys and girls were heavier as compared to both the CGs. IG boys were 810 g heavier than CG-I boys and 950 g heavier than CG-II boys, whereas, IG girls weighed 1000 g and 1180 g heavier than CG-I and CG-II girls, respectively. The effect size of difference between both the groups was small (d= 0.20 to 0.50 at p<0.001) as per Cohen’s rule.

Attained length

At 12 months of age, IG boys and girls were also longer than CG-I and CG-II boys and girls. IG boys were longer by about 2.99 cm and 3.23 cm in comparison to CG-I and CG-II boys, respectively, whereas the IG girls were longer by about 3.90 cm and 3.05 cm as compared to CG-I and CG-II, respectively (Table 4b). The effect size of difference between the groups was of medium magnitude especially in case of girls (d1=0.533 and d2= 0. 479 at p<0.001).

Attained BMI

IG infants had comparatively higher BMI than CG-I and CG-II infants between 6-12 months of age (Table 4c). The difference was significant (p <0.01) only at 12 months of age between IG

Table 2: Quality of Complementary feeding practices as per CFI in the three groups.

Feeding Practices %

6 mo χ2 9 mo χ2 12 mo χ2

φI πC-I λC-II φI πC-I φI πC-I λC-II

Breast Feeding 98.4 98.4 95.3 NS 98.4 69.8 a** 87.1 69.8 76.6 a*

Uses baby bottle 48.4 36.5 65.6 c** 9.7 92.1 a** 8.7 68.2 75.0 a & b **Timely initiation of CF (at completion of 6 months) 96.8 6.3 6.2 a & b ** 96.8 6.3 a** 96.8 6.3 6.2 a & b **

≥ 2 meals (for 6 to 8 months) 75.8 8.6 6.4 a & b ** NA NA NA NA NA NA NA

≥ 3 meals (for 9 to 12 months) NA NA NA NA 87.1 7.6 a** 88.7 14.0 30.0 a & b**, c*

≥ 3 food groups (for 6 to 8 months) 96.8 0.0 1.6 a & b ** NA NA NA NA NA NA NA

≥ 4 food groups(for 9 to 12 months) NA NA NA NA 79.0 14.3 a** 93.5 7.9 3.1 a, b**

Starchy staples 100.0 17.5 20.3 a & b ** 100.0 84.1 a** 100.0 84.1 92.2 a **

Legumes 95.2 4.8 4.7 a & b ** 100.0 49.2 a** 100.0 50.8 26.6 a & b**, c*

Milk and milk products 98.4 9.5 53.1 a, b & c ** 100.0 88.9 a* 100.0 90.5 92.2 a*

Egg/Meat 14.5 1.6 1.6 a & b * 1.6 6.3 NS 6.5 4.8 0.0 NS

Vitamin A rich fruits/vegetables 72.6 0.0 0.0 a & b ** 100.0 9.5 a** 100.0 17.5 31.3 a & b **

Other fruits/vegetables 83.9 3.2 3.1 a & b ** 100.0 44.4 a** 79.0 25.4 26.6 a & b **

Food made with oil/fat/butter 53.2 0.0 1.6 a & b ** 100.0 61.9 a** 100.0 60.3 82.8 a, b & c**φIntervention group (I): n=62, πComparison group-I (C-I): n=63, λComparison group-II (C-II): n=64. NA: Not Applicable, NS: Not SignificantData presents percentages and significant chi-square with their level of significance. a–Significant Pearson chi square between Intervention & Comparison-I, b- Significant Pearson chi square between Intervention & Comparison-II, c- Significant Pearson chi square between Comparison-I & Comparison-II. *value significant at p ≤ 0.05. **value significant at p ≤0.01




Table 3: Prevalence of diarrhoea, fever, cough and cough with rapid breathing (ARI) in infants of the three study groups between enrollment and end-line.

Age (months) Study area nPrevalence of illness (%)

Diarrhoea Fever Cough Cough with rapid breathing (ARI)

I 62 58.1 52.9 53.2 20.54 C-I 63 57.1 25.4 22.2 12.7

C-II 64 51.6 27.2 25.6 12.5χ2 NS a & b** a & b** NS

6I 62 32.3 27.4 27.4 16.1

C-I 63 47.6 33.3 27.0 12.7C-II 64 45.3 20.3 18.8 10.9χ2 NS NS NS NS

8I 62 37.1 29.0 33.9 1.6

C-I 63 55.6 47.6 38.1 15.9χ2 a* a* NS a **

10I 62 35.5 22.6 21.0 9.7

C-I 63 63.5 50.8 46.0 9.5χ2 a** a** a** NS

12I 62 33.9 25.8 12.9 4.8

C-I 63 42.9 44.4 34.9 3.2C-II 64 56.3 37.5 14.1 4.7χ2 b* a* a & c** NS

I: Intervention area, C-I: Comparison area I, C-II: Comparison area II, NS: Not SignificantData presents percentages and significant chi-square with their level of significance. a–Significant Pearson chi square between Intervention & Comparison-I, b- Significant Pearson chi square between Intervention & Comparison-II, c- Significant Pearson chi square between Comparison-I & Comparison-II. *value significant at p ≤ 0.05. **value significant at p ≤0.01

Table 4 (a): Mean weight of infants during follow-up in the three study groups.

Age (Completed months) Sex

Weight (kgs) Difference

between I & C-I (kg)

Difference between I & C-II (kg)

Intervention (I)

Comparison-I (C-I)

Compari-son-II (C-II)

n Mean SD n Mean SD n Mean SD Mean (95% CI)

Mean (95% CI)

4

Boys 33 5.71 0.43 40 5.64 0.58 34 5.52 0.54 0.07 0.19[(-0.22)-(-0.36)] [(-0.11)-(-0.49)]

Girls 29 5.20 0.58 23 5.03 0.52 30 5.20 0.62 0.17 -0.00(-0.22-0.55) (-0.37-0.35)

6

Boys 33 6.63 0.56 40 6.53 0.62 34 6.30 0.60 0.10 0.32[0.23 -(-0.44)] [(-0.02)-(-0.67)]

Girls 29 6.15 0.67 23 5.89 0.67 30 5.93 0.63 0.26 0.22(-0.17-0.70) (-0.18-0.62)

8

Boys 33 7.48 0.60 40 7.03 0.68 34 N.A. 0.39* N.A.(0.09-0.69)

Girls 29 6.87 0.69 23 6.46 0.67 30 N.A. 0.41* N.A.(0.30-0.79)

10

Boys 33 8.08 0.52 40 7.44 0.71 34 N.A. 0.63** N.A.(0.33-0.92)

Girls 29 7.53 0.66 23 6.84 0.72 30 N.A. 0.68** N.A.(0.29-1.07)

12

Boys 33 8.67 0.47 40 7.86 0.63 34 7.72 0.72 0.81** 0.95**[(-0.46)-(-1.15)] [(-0.59)-(-1.31)]

Girls 29 8.33 0.61 23 7.32 0.69 30 7.14 0.69 1.00** 1.18**(0.56-1.45) [0.77- (-1.60)]

N.A. – Data not collected for C-II group at 8 and 10 months of ageData is presented as Mean, SD and difference between the mean with significance levels in Post Hoc (Tukey HSD test)*significant difference between groups at p value ≤ 0.05; ** significant difference between groups at p value ≤ 0.01.




Table 4 (b): Mean length of infants during follow-up in the three study groups.

Age (Com-pleted

months)

Sex

Length (cm)

Difference between I & C-I (cm)

Difference between I & C-II (cm)

Interven-tion (I)

Comparison-I (C-I)

Comparison-II

(C-II)


Mean (95% CI)

4

Boys 33 60.37 1.44 40 60.20 1.72 34 59.80 1.99 0.17 0.57(-0.80-1.13) (-0.44-1.57)

Girls 29 58.92 1.95 23 58.00 1.87 30 59.21 1.64 0.91 -0.29 (-0.29- 2.13) (-1.42 – 0.84)

6

Boys 33 63.46 1.40 40 63.24 1.84 34 62.56 2.19 0.22 0.80(-0.81-1.25) (-0.26-1.87)

Girls 29 61.84 2.22 23 60.86 2.17 30 60.70 1.92 0.98 0.84 (-0.41- 2.39) (-1.16 – 1.44)

8

Boys 33 67.35 1.66 40 65.98 1.91 34 N.A. 1.37** N.A.(0.53-2.21)

Girls 29 65.66 2.29 23 63.26 1.98 30 N.A. 2.39 ** N.A.(1.18 – 3.61)

10

Boys 33 70.48 1.56 40 68.05 1.65 34 N.A. 2.43** N.A.(1.67-3.18)

Girls 29 69.06 1.49 23 65.55 2.07 30 N.A. 3.50** N.A.(2.51 – 4.49)

12

Boys 33 73.09 1.38 40 70.10 2.03 34 69.86 2.05 2.99** 3.23**(1.95-4.03) (2.15-4.31)

Girls 29 71.68 1.48 23 67.78 2.23 30 68.63 1.74 3.90** 3.05**(2.69 – 5.10) (1.92 – 4.17)

N.A. – Data not collected for C-II group at 8 and 10 months of ageData is presented as Mean, SD and difference between the mean with significance levels in Post Hoc (Tukey HSD test)*significant difference between groups at p value ≤ 0.05; **significant difference between groups at p value ≤ 0.01.

Table 4 (c): Mean BMI of infants during follow-up in the three study groups.

Age (Completed

months)Sex

BMI (kgs/m2)Difference

between I & C-I (kgs/m2)

Difference between I & C-II

(kgs/m2)Intervention

(I)Comparison-I

(C-I)Comparison-II

(C-II)

n Mean SD n Mean SD n Mean SD Mean 95% CI)

Mean (95% CI)

4

Boys 33 15.68 1.03 40 15.54 1.24 34 15.42 0.89 0.14 0.27(-0.46-0.74) (-0.36-0.89)

Girls 29 14.95 1.16 23 14.93 1.17 30 14.81 1.34 0.02 0.14(-0.80-0.84) (-0.63-0.90)

6

Boys 33 16.45 1.12 40 16.30 1.01 34 16.04 0.98 0.15 0.41(-0.42-0.73) (-0.19-1.01)

Girls 29 16.07 1.17 23 15.87 1.31 30 15.55 1.07 0.20 0.51(-0.59-0.98) (-0.22-1.24)

8

Boys 33 16.37 1.04 40 16.14 0.97 N.A. 0.23 N.A.(-0.25-0.70)

Girls 29 15.94 1.26 23 16.13 1.30 N.A. -0.19 N.A.(-0.91-0.53)

10

Boys 33 16.26 0.82 40 16.06 1.06 N.A. 0.20 N.A.(-0.25-0.65)

Girls 29 15.78 1.15 23 15.90 1.18 N.A. -0.12 N.A.(-0.77-0.53)

12

Boys 33 16.23 0.78 40 16.00 0.84 34 15.79 0.92 0.24 0.44(-0.24-0.71) (-0.05-0.94)

Girls 29 16.21 0.98 23 15.92 0.99 30 15.14 0.93 0.29 1.07**(-0.35-0.93) (0.47-1.67)

N.A. – Data not collected for C-II group at 8 and 10 months of ageData is presented as Mean, SD and difference between the mean with significance levels in Post Hoc (Tukey HSD test)**significant difference between groups at p value ≤ 0.01.




and CG-II girls. The mean BMI-for-age z scores for IG infants was also comparatively higher than CG-I infants at all ages and CG-II group infants at 4, 6 and 12 months of age. But, the difference between IG and CGs was only significant (p <0.01) at 12 months of age when IG girls had higher mean BAZ than CG-II girls by 0.79.

Weight Velocity

Mean bi-monthly weight gain for IG boys was significantly (p <0.01) higher than CG-I infants between 6 to 12 months of age. In case of girls, the difference was significant between 8 to 12 months of age (p <0.01). The IG infants had a better bi-monthly weight velocity as compared to WHO [16] standard medians between 6 to 12 months of age (Table 5a).

Length velocity

IG infants had a higher length velocity than CG-I infants. Difference was significant between 6-8 months, 8-10 months (p <0.01) and 10-12 months of age (only for boys). The length increment between 6-12 months of age was observed to be higher for boys than girls. IG infants gained significantly higher length than both CG-I and CG-II infants (p <0.01) between 6-12 months of age (Table 5b).

Underweight Prevalence

As presented in Table (6), intervention resulted in 40% point reduction in underweight prevalence rates in IG between 4 to 12 months of age as compared to 13% point reduction in CG-I and 4.6% point increase in CG-II.

Stunting Prevalence

Significant reduction in stunting prevalence was observed in IG v/s CG-I (at 8 and 10 months of age, p <0.01) and CG-II (at

12 months of age, p <0.01). A 24.3% point reduction in stunting prevalence was observed in IG between enrollment and end line (Table 6).

Wasting Prevalence

Intervention resulted in a significantly lower (p<0.01) wasting prevalence in IG (reduction by 6.5 % points) at 12 months of age as compared to CG-I and CG-II (Table 6).

Qualitative information was collected at end-line to understand the facilitators and influencers of CBNC approach which contributed to the study outcomes. Following were the key lessons’ learnt from the CBNC approach, which helped in achieving the study outcomes: (i) Formative research facilitated in identifying and standardizing the most feasible key intervention messages in order to address the principal challenges to CF in the target population. (ii) Use of intervention counseling tool (pictorial flip book) in the capacity building of service providers, coupled with enhancing their skills on use of ‘checking questions’ and ‘praise’ to ensure mothers’ correct understanding and motivation, proved effective in building capacity of service providers. Capacity building outcome was enriched by inclusion of discussions, exercises, food demonstration, videos, role plays, practice using job aids as well as practical hands on training sessions pertaining to IPC in classroom and community settings. The pictorial counseling aids also facilitated consistency in delivery of key intervention messages and confidence building of CCs, AWWs, ANMs and other stakeholders. (iii) Strengthening and enhancing the capacity of existing health and nutrition service delivery platforms (of ICDS and Health programs) contributed to consistent delivery of key intervention messages at multiple contacts opportunities. (iv) Engaging and establishing linkages with religious leaders, school teachers and local village doctors

Table 5 (a): Mean bi-monthly weight increment during follow-up in the three study groups.

Weight increment Age interval (Completed months)

Sex

Weight increment (g) Difference between I & C-I

(g)

Difference between I & C-II (g)Intervention

(I)Comparison-I

(C-I)Comparison-II

(C-II)


Mean(95% CI)

Weight increment from 4 to 6 months

Boys 33 914.85 262.89 40 885.63 317.87 34 781.50 253.57 29.22 133.35(-128.49-186.94) (-30.54-297.23)

Girls 29 955.17 308.98 23 860.57 367.67 30 729.80 223.40 94.61 225.37*(-105.26-294.47) (38.96-411.78)


Boys 33 800.00 281.68 40 512.38 326.41 N.A. 287.63** N.A.(143.64-431.61)

Girls 29 719.14 305.44 23 571.96 390.34 N.A. 147.18 N.A.(-46.51-340.88)


Boys 33 648.03 305.26 40 408.88 327.61 N.A. 239.16** N.A.(90.17-388.14)

Girls 29 656.72 271.35 23 383.91 234.05 N.A. 272.81** N.A.(129.46-416.16)


Boys 33 593.33 374.80 40 420.50 259.97 N.A. 172.83* N.A.(24.23-321.44)

Girls 29 800.34 298.00 23 478.70 205.12 N.A. 321.65** N.A.(175.15-468.15)

N.A. – Data not collected for C-II group at 8 and 10 months of ageData is presented as Mean, SD and difference between the mean with significance levels in Post Hoc (Tukey HSD test)*significant difference between groups at p value ≤ 0.05; **significant difference between groups at p value ≤ 0.01.




Table 5 (b): Mean bi-monthly length increment during follow-up in the three study groups.

Length increment Age interval

(Completed months)Sex

Length increment (cm) Difference between I &

C-I (cm)

Difference between I & C-II

(cm)Intervention

(I)Comparison-I

(C-I)Comparison-II

(C-II)


Mean (95% CI)

Length increment from 4 to 6 months

Boys 33 3.09 0.63 40 3.04 1.18 34 2.86 0.90 0.06 0.24

(-0.47-0.58) (-0.31-0.78)Girls 29 2.92 1.67 23 2.85 0.74 30 2.49 0.99 0.07 0.43

(-0.75-0.89) (-0.33-1.19)

Length increment from 6to 8 months

Boys 33 3.89 0.95 40 2.74 1.15 N.A. 1.15** N.A.(0.65-1.65)

Girls 29 3.81 0.95 23 2.40 0.75 N.A. 1.41** N.A.(0.93-1.90)


Boys 33 3.13 0.96 40 2.07 0.72 N.A. 1.06** N.A.(0.66-1.45)

Girls 29 3.41 1.25 23 2.30 0.82 N.A. 1.11** N.A.(0.15-1.72)


Boys 33 2.61 0.92 40 2.05 0.70 N.A. 0.56** N.A.(0.19-0.94)

Girls 29 2.62 0.87 23 2.23 0.77 N.A. 0.39 N.A.(-0.07-0.86)

N.A. – Data not collected for C-II group at 8 and 10 months of ageData is presented as Mean, SD and difference between the mean with significance levels in Post Hoc (Tukey HSD test)*significant difference between groups at p value ≤ 0.05; ** significant difference between groups at p value ≤ 0.01.

Table 6: Prevalence of Underweight, Stunting and Wasting in the three study groups.

Age (months) Study arean Prevalence of Undernutrition (%)

Underweight (WAZ<-2SD) Stunted (HAZ <-2SD)

Wasted(WHZ<-2SD)

I 62 40.3 29.1 6.5

4 C-I 63 49.2 38.1 7.9

C-II 64 48.5 26.6 12.5

χ2 NS NS NS

6

I 62 35.5 50.0 1.6

C-I 63 47.6 49.2 1.6

C-II 64 42.2 51.6 3.1

χ2 b* NS NS

8I 62 17.8 25.8 1.6

C-I 63 47.6 58.8 1.6

χ2 a** a** NS

10I 62 6.5 4.8 3.3

C-I 63 46.0 60.3 6.3

χ2 a** a** NS

12

I 62 0.0 4.8 0.0

C-I 63 36.5 65.0 6.3

C-II 64 53.1 67.2 12.5

χ2 a & b** a & b** b**I: Intervention area, C-I: Comparison area I, C-II: Comparison area II. Data presents percentages and significant chi-square with their level of significance. a–Significant Pearson chi square between Intervention & Comparison-I, b- Significant Pearson chi square between Intervention & Comparison-II, c-

Significant Pearson chi square between Comparison-I & Comparison-II. *value significant at p ≤ 0.05. **value significant at p ≤0.01, NS: Not SignificantNote: z-scores calculated using WHO (2006)15 Standards




served as valuable delivery platforms for delivery of intervention messages and contributed to improved acceptance of the interventions messages by the target families. It also contributed to enhanced involvement of male members in the childcare and feeding behaviors as well as spreading the key messages to the larger audience. (v) Use of a self-tracking tool in the form of AWC micro plan for monthly planning and monitoring on programme indicators for their area contributed towards improved quality of service delivery at AWC (vi) Supportive supervision coupled with recognition and respect of village level service providers proved effective in enhanced self-esteem of service providers (AWWs, ANMs and CCs). Recognition through non-monitory incentives like certificates, badges and trophies by District officials and village head motivated them to deliver AWC services with quality. (vi) Food demonstration at household level on preparing and feeding infants’ age-appropriate complementary foods helped in building the confidence of the mothers and caretakers. Mothers gained confidence in feeding their child with appropriate quality, quantity and consistency of complementary foods, especially by adapting the local family food. It also helped in dispelling beliefs of families regarding CF practices as well as helping the mothers in practicing responsive feeding behaviors to feed their infants (vii) Planting kitchen garden in the infant’s house together with counseling on use of the vegetables in infant’s diet contributed in inclusion of green leafy and yellow vegetables in infants’ diet and thus improving the dietary diversity scores if IG infants.

The study demonstrated that intervention in the form of CBNC approach improved caregivers’ practices on age-appropriate CF and optimal breastfeeding as evidenced by improved CFI scores, reduced morbidity and improved physical growth of IG infants. The current study complements the findings of community-based studies from other countries where training community-based volunteers or peer counselors resulted in significant improvement in the adoption of CF practices and growth of the infants [6,9].

Over the years, inadequately documented experiences and results have led to lack of practical, field tested frameworks, processes and tools that can be applied in diverse contexts, delaying the investments and action in the area of improving CF [21] Our study has generated new evidence in rural Indian settings on the implementation of a practical CBNC approach for improved delivery of age-appropriate CF counseling.

A review on CF interventions [5] recommends that for reducing the problem of stunting, CF interventions should show impact on quality and quantity of complementary food, breast milk intake and morbidity. Our study demonstrated and confirmed that improved quality and quantity of complementary food, improved hygiene and responsive feeding practices, breast feeding practices and reduced morbidity resulted in improved linear growth as measured by higher length gain, better length velocity and reduced stunting rates in IG as compared to CG-I and CG-II. The magnitude of impact of intervention was higher on the mean length of IG infants as compared to CGs infants at 12 months of age as measured by higher effect size. Our study findings are comparable to some other community-based educational trials on CF from Peru [8] and China [22], which also demonstrated improvement in CF as well as significant improvement in the

length gain of intervention infants as compared to control group infants. Another educational intervention trial from India showed small but significant effect on length gain in intervention group at 12 months of age with no change in weight gain [9]. Contrary to the present study findings, some other studies from China [5], Bangladesh [23] and India [10,11] failed to show a significant impact of CF educational intervention on length gain of intervention infants by 12 months of age, though these studies reported significant impact on mean WAZ sores and weight gain.

The lessons’ learnt and the recommendations of the present study from implementing the CBNC approach are in line with the recently published evidence on the key principles to improve CF programmes and interventions [3] as well as the recommendations derived from IYCF programming in Bangladesh, Ethiopia and Vietnam.[21,24] In line with our study findings, the significance of formative research and positive implication of system strengthening in influencing young child feeding has been also been stressed upon in studies from other developing countries [3,24,25]. Our study results and recommendations have significant implications for designing community-based interventions for prevention of child under nutrition focusing on improving the CF practices and growth within similar rural settings in other countries. Though it was not in the scope of our study, but based on our observations and experience during the study, we feel that the effectiveness of community-based programmes on infant feeding can further be enhanced with supportive nutrition sensitive interventions, with specifically improved infrastructure availability at village level such as functional sanitation and safe water supply and access to reasonable quality of basic health services at the door step.

CONCLUSIONThe study demonstrated the implementation and

documented results of a community-based approach to improve the CF practices and growth of infants from rural setting in Uttar Pradesh, India. This piece of evidence shows that CBNC approach improved caregivers’ knowledge and practices on age-appropriate CF, optimal breastfeeding, infants’ morbidity and growth. The core interventions of the CBNC approach namely- capacity building, system strengthening, BCC, synergy with local bodies and kitchen garden at the household level, derived lessons and generated evidence for scaling up the approach in similar rural settings in India as well as other country settings. Though the CBNC approach showed positive outcome in the form of improved CF practices and improved growth of infants through its core interventions in the study settings, but there is a need to further test the effectiveness of this approach on a larger sample and in other rural settings before scale-up.

ETHICAL CLEARANCEThe study was approved by the Departmental Research

Committee of University of Delhi, India. Informed written consent was obtained from all the study participants and their family members on their participation in the study.

ACKNOWLEDGEMENTSThe findings of the study were presented at the National

Conference of Nutrition Society of India in November 2013. The




work was supported by scholarship grant from University Grants Commission, India. (Scholarship number: JRF/AA/37/2004-05/3328).

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Garg A, Chadha R (2016) Community-Based Nutrition Counseling Improves Complementary Feeding Practices and Growth of Infants (6-12 Months) in Rural Uttar Pradesh, India. J Hum Nutr Food Sci 4(5): 1099.

Cite this article

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