ABSTRACT
Malnutrition is still a big menace in sub-Saharan Africa as approximately 48 percent of children below five years and 20 percent of pregnant-age women suffer from the effects of Vitamin A deficiency (VAD); night blindness, increased child morbidity and mortality. Biofortified staples have been promoted widely in the region as a sustainable way of addressing the undernutrition problem. Recent studies have shown that these foods can contribute to the fight against malnutrition, and are accepted by young children. However, the existing initiatives used in promoting the vitamin A biofortified orange-fleshed sweetpotato (OFSP) have borne fruits, whose impacts have seldom been felt beyond the borders of the direct beneficiaries and the active periods of the projects. Nevertheless, the potential role of simultaneous nutrition education dissemination to preschool children and their caregivers on the continued production and consumption of fresh biofortified food remain much less understood. Thus, the main objective of this study was to assess the effects of disseminating nutrition education to preschool children and their caregivers on the production and consumption of OFSP.
The objectives of the study were to assess the effects of integrated nutrition education approaches on; i) the caregivers‟ knowledge, attitude and practices (KAP) around OFSP; ii) the caregivers‟ likelihood to replant OFSP after phase-out of the free vines dissemination projects; and iii) the consumption of OFSP among preschool children. The study was guided by the random utility theory and employed a randomized controlled trial approach. Participants were selected through a multistage sampling technique. The first stage gave a purposive sample of 15 villages that had no prior interaction with OFSP promotion projects in the Ndhiwa and Rangwe Sub-counties of Homa Bay County. The second stage involved using proportionate to size sampling and simple random sampling techniques to choose 431 preschooler-caregiver pairs who participated in preliminary activities of the study - cooking demonstrations and dissemination of free vines. The 15 villages were randomized into four groups (one control and three treatment groups) and all participants in the groups were assigned the respective interventions. The treatments involved the issuance of nutrition education; i) to preschool children alone via OFSP- branded exercise books, class posters, and poems; ii) to caregivers alone by sending bulk nutrition education messages to their phones; and iii) to both the preschooler and the caregiver simultaneously using the same methods in other treatment arms. Baseline and follow-up survey data were collected using structured questionnaires. Also, a dietary diversity register was used to collect data on the preschoolers‟ consumption of OFSP during school days. The effects of the treatments were elicited by estimation of the generalized linear regression model (GLM), special regressor method (SRM), and the zero-inflated Poisson (ZIP) regression model in line with the three hypotheses, respectively. The results show that only the multiple-channel oriented nutrition education gave significant improvements in all the dimensions of the caregivers‟ knowledge of OFSP. It also improved the likelihood of the caregivers to retain the OFSP on their farms significantly while the single- channel approaches failed to provide any significant improvements. Further, both the single and multiple-channel oriented nutrition education approaches increased the number of days on which the preschool children were fed on the OFSP roots. Overall, the magnitude of the effect of OFSP nutrition education interventions was significantly improved by delivering the nutrition education through multiple channels and ensuring higher rates of reception of the assigned interventions by the target group. Accordingly, the study concludes that the integration of complementary nutrition education interventions, delivered through the Early Childhood Development (ECD) platforms, can enhance the supply of and demand for nutritious crops such as OFSP in the menus of malnutrition high risk groups to improve food and nutrition security. The study recommends that agriculture-nutrition education interventions should consider both preschoolers‟ learning materials and the caregivers‟ mobile phones as effective platforms for nudging the caregivers to adopt the biofortified staples sustainably.
Key words: malnutrition; nutrition education; orange-fleshed sweet potato; replanting; consumption.
TABLE OF CONTENTS
DECLARATION i
DEDICATION ii
ACKNOWLEDGEMENTS iii
LIST OF TABLES viii
LIST OF FIGURES ix
LIST OF ABBREVIATIONS AND ACRONYMS x
ABSTRACT xi
CHAPTER ONE: INTRODUCTION
1.1 Background 1
1.2 Statement of the Research Problem 4
1.3 Objectives of the Study 5
1.4 Research Hypotheses 5
1.5 Justification 6
1.6 Study Area 8
CHAPTER TWO: LITERATURE REVIEW
2.1 The Role of Nutrition Education in Enhancing Behavior Change and Nutrition Security. 11
2.2 A Review of Previous Nutrition Interventions with Preschool Children 12
2.3 Treatment Effects 13
2.4 Consumption of OFSP 14
2.5 Conceptual Framework 15
2.6 Theoretical Framework 17
CHAPTER THREE: EFFECTS OF INTEGRATED NUTRITION EDUCATION APPROACHES ON CAREGIVERS‟ KNOWLEDGE, ATTITUDE AND PRACTICES REGARDING OFSP
3.1 Abstract 19
3.2 Introduction 20
3.3 Methodology 22
3.3.1 Sampling and Selection of Participants 22
3.3.2 Sample Size Determination 23
3.3.3 Experimental Design and Interventions 24
3.3.4 Data Collection 26
3.3.5 Measurement of Caregivers‟ KAP Constructs 26
3.3.6 Data Analysis 28
3.4 Results and Discussion 32
3.4.1 Attrition 32
3.4.2 Sample Characteristics 33
3.4.3 Distribution of KAP Scores across Study Groups and Time 35
3.4.4 Mean Changes in KAP Scores 39
3.4.5 Treatment Effects 40
3.5 Discussion 42
3.6 Conclusion 43
CHAPTER FOUR: EFFECTS OF INTEGRATED NUTRITION EDUCATION INTERVENTIONS ON THE LEVEL OF REPLANTING OFSP AMONG CAREGIVERS
4.1 Abstract 45
4.2 Introduction 45
4.3 Objective and Methodology 47
4.4 Results 48
4.4.1 OFSP Production 48
4.4.2 Participation in the Study Interventions 50
4.4.3 Treatment Effects 51
4.5 Discussion 55
4.6 Conclusion 57
CHAPTER FIVE: EFFECTS OF INTEGRATED NUTRITION EDUCATION APPROACHES ON THE CONSUMPTION OF OFSP AMONG PRESCHOOLERS
5.1 Abstract 58
5.2 Introduction 59
5.3 Objective and Methodology 62
5.3.1 Instruments and Data Collection 62
5.3.2 Measurement of OFSP Consumption Frequency 64
5.3.3 Data Analysis 64
5.4 Results 68
5.4.1 Summary Statistics 68
5.4.2 The Relationship between OFSP Production and Consumption Trends 72
5.4.3 Effects of Nutrition Education Intervention on OFSP Consumption and Consumption Frequency 75
5.5 Discussion 77
5.6 Conclusion 79
CHAPTER SIX: GENERAL DISCUSSION, CONCLUSION AND RECOMMENDATIONS
6.1 General Discussion
6.2 Conclusion 83
6.3 Recommendations 83
REFERENCES 86
APPENDICES 102
Appendix A: Sample Treatment Materials 102
Appendix A1: A Sample Cover Page of OFSP-Branded Exercise Books 102
Appendix A2: Sample OFSP-Branded Class Posters 103
Appendix A3: Mobile Phone-Mediated Messages 104
Appendix B: Household Survey Questionnaire 105
Appendix C: Dietary Diversity Register 118
Appendix D: Estimation of OFSP Consumption Data with more Covariates 119
Appendix D1: Extended models for estimating the probability and frequency of OFSP consumption 119
Appendix D2: Model specification for estimating the likelihood and frequency of OFSP consumption 121
LIST OF TABLES
Table 1: Unadjusted Means and Differences in Means of the Main Outcome Variables at Baseline between the Attrited and Non-Attrited Sample 32
Table 2: Cross-tabulation and Chi-square Test for Significant Relationship between Study Groups and Attrition 33
Table 3: Distribution of the Socio-Demographic Variables across the Study Groups 34
Table 4: Mean Scores of Caregivers KAP Scores Before and After the Intervention across the Study Groups 36
Table 5: Mean Changes in Caregivers‟ KAP Scores (Follow-up minus Baseline Scores) by Study Groups 40
Table 6: GLM Estimates for Mean Change in OFSP Knowledge, Attitude, and Practices among the Caregivers of Preschool Children in the Study Sample† 41
Table 7: Logit Regression Results - Average Marginal Effects Estimates of Nutrition Education Interventions and Other Covariates on Retention of OFSP 52
Table 8: SRM Results - Marginal Effect Estimates of Nutrition Education Interventions and other Covariates on Retention of OFSP 54
Table 9: Summary Statistics and Test for Differences in Variable Means between Control and Treatment Groups (at Baseline) for Sample Used in Consumption Analysis 70
Table 10: The Effect of Nutrition Education Interventions on the OFSP Consumption and Consumption Frequency 76
LIST OF FIGURES
Figure 1: The Map of Study Locations in Homa Bay County, Kenya 10
Figure 2: Conceptual Framework of How Nutrition Education Contribute to Improved Nutritional Status among Young Children 17
Figure 3: A consort diagram of the study 31
Figure 4: Trends of Mean KAP Scores Before and After the Intervention by the Study Groups 38 Figure 5: Caregivers‟ Engagement with OFSP across the Study Groups 49
Figure 6: Assignment and Acknowledgment of the Interventions among Caregivers 51
Figure 7: Distribution of Consumers of OFSP across the Study Groups and OFSP Production 73 Figure 8: Percentage of Preschoolers by OFSP Production and Frequency of Consumption in the Study Groups 74
LIST OF ABBREVIATIONS AND ACRONYMS
AVCD Accelerated Value Chain Development
BCC Behavior Change Communication
CIP International Potato Center (Centro Internacional de la Papa )
ECD Early Childhood Development
FAO Food and Agriculture Organization of the United Nations
GDP Gross Domestic Product
GLM Generalized Linear Model
IFAD International Fund for Agricultural Development
IFPRI International Food Policy Research Institute
KAP Knowledge, Attitude and Practices
NCPD National Council for Population and Development
OFSP Orange-Fleshed Sweet Potato
RCT Randomized Control Trials
SDGs Sustainable Development Goals
SRM Special Regressor Model
SSA Sub-Saharan Africa
UNICEF United Nations Children‟s Education Fund
USAID United States Agency for International Development
VAD Vitamin A Deficiency
WFP World Food Programme
WHO World Health Organization
ZIP Zero-Inflated Poisson
CHAPTER ONE: INTRODUCTION
1.1 Background
Despite the concerted global efforts to address the problem, undernutrition prevalence has increased from 785 million people in 2015 to 821 million in 2018 (FAO et al., 2019). Due to this, more than 3 million children are lost per year to malnutrition, as 155 million of the under 5-year- old are stunted. One key contributor to child and maternal malnutrition is hidden hunger - deficiency in essential vitamins and micronutrients, which has strong devastating effects on the physical and cognitive growth and development of young children.
Vitamin A deficiency (VAD), a form of micronutrient deficiency, affects the immune system of individuals, thereby jeopardizing their health and increasing the risks of poor cognitive development; morbidity, especially from diarrhea and measles; and mortality (WHO, 2015; Rice et al., 2004). It has also been linked to increased rates of mother-to-child transmission of the Human Immunodeficiency Virus (HIV) in addition to the progression of diseases among HIV- positive adults and general immune functions linked to severe visual impairment and blindness (Annan, 2011; McHenry et al., 2015; WHO, 2018).
Bio-fortification is a technology that boosts the density of vitamins and minerals in the plant food through agronomic practices and breeding so that when consumed regularly, they would create measurable improvement in the vitamin and mineral status (Zikankuba et al., 2019). The technology is promoted globally to enhance the nutrition conditions of targets. Besides, it is highly cost-effective at the rate of $15-$20 per disability-adjusted life year (DALY) saved (Bouiss and Saltzam, 2017; Meenakshi et al., 2010). Orange-fleshed sweetpotato (OFSP) is a leading case of a vitamin A biofortified product that is promoted and embraced by the target society in equal measures. It has better agronomic and nutritional traits, including faster maturity, high yield potential and endowed with rich-nutrients (Low et al., 2017).
Agriculture-nutrition sensitive programs have been promoted as relatively more sustainable and cost-effective strategies for addressing the malnutrition problem among rural farming households in the global south, especially the SSA (Olney et al., 2019; Ruel et al., 2013&2018; Ruel, 2018; Zikankuba et al., 2019). However, according to contemporary reviews, the potential of the agri- nutrition education programs on nutrition security is way far from full realization. Nonetheless, there is an active line of positive evidence that links these programs to improvements in the nutritional status of the target groups. What is lacking is concerted effort to design more differentiated and effective agriculture-nutrition programs to help scale up the fight against malnutrition beyond the current rates (Olney et al., 2019; Ruel et al., 2018; Zikankuba et al., 2019.
The nutrition-sensitive interventions have followed the principle of targeting and integrating vulnerable groups to maximize project impacts (Bos et al., 2015). Accordingly, rural farming households are encouraged to change their farming routines and dietary behavior if they are to sustainably adopt the OFSP (Zikankuba et al., 2019). That is, for the continuous availability of the OFSP in their menus, farmers need to conserve the vines and plant them in consecutive planting seasons and consume OFSP as they harvest from their farms. In order to influence such changes, research has shown that well designed and carefully implemented nutrition-sensitive agricultural programs can improve young-child and maternal nutrition when they include information on the agronomic and nutritional benefits of the food crop, strong behavior change communication (BCC) and interventions that empower women (Rue et al., 2013; Muehlhoff et al., 2017; Mutiso et al., 2018).
For a long time, most of the nutrition-sensitive programs focused on the 1000 days of a young child and left out the preschool child (mostly 2-6 years) until they joined the primary school levels (Bos et al., 2015; Gelli et al., 2018). This realization has led to a shift in intervention targeting protocols, to include the Early Childhood Development (ECD) platform, to enhance the fight against malnutrition. Nevertheless, nutrition is critical to the overall health and well-being of an individual throughout their life cycles, thus the need to train a child towards healthy nutritional decisions from the tender age.
Women and children are the most vulnerable groups to VAD cases. Therefore, interventions that aim to eradicate VAD perform better if they reach this target group (Ruel et al., 2017). Previous studies have shown that children can be effective nudges to their parents, and several studies have reported significant differences in interventions that used children as change agents (Murimi et al., 2017&2018). However, the potential effect of engaging preschoolers and their caregivers with intensive nutrition education is limited in the empirical literature. Consequently, such collective avenues that bring together the malnutrition-vulnerable groups could be losing their potential in contributing to the fight against malnutrition. In essence, integrating agriculture-nutrition education interventions through the ECD platform may provide a mechanism for accelerating the scalability and effectiveness of the food-based strategies against malnutrition.
Early Childhood Development and Education (ECDE) centers in Kenya are managed by the county governments. They play an important role in providing learning and holistic development of children, mostly between 3 and 5 years. Homa Bay county has 1183 such centers with an enrolment rate of 76% (County Government of Homa Bay, 2018).
In the context of this study, a preschooler is defined as a child between 3 and 7 years who has not been introduced to the primary level of school (Grade 1), but is linked to the nearby ECD institution. A caregiver refers to the person who prepares and feeds the preschooler in the household.
1.2 Statement of the Research Problem
Despite being highly endowed with relatively fertile agricultural land, favorable agro-climatic conditions and two planting seasons, Homa Bay county is still faced with a high rate of undernutrition (Bernstein and Wiesmann, 2018; Delorme et al., 2018). It is also recognized as one of the leading producers of sweetpotato in Kenya (Abong et al., 2016). Conventional malnutrition eradication strategies (such as vitamin A supplementation, industrial food fortification) have persistently underserved the population. For instance, the 2-dose vitamin A supplementation program, implemented by the county government, reportedly served only 42 percent of under-5-year old children in 2017 (County Government of Homa Bay, 2018). A larger share of the county is rural, and farming is the main livelihood activity. The OFSP was introduced in the county more than a decade ago; however, the spread of the residents' awareness and active engagement with the crop for nutrition security beyond the direct beneficiaries and the promotional project periods is limited.
Nutrition education has been promoted as one of the best methods of implementing behavior change communication, to empower the vulnerable target groups towards making effective changes in dietary and nutrition-related behaviors (Marias and Glasauer, 2014; Mutiso et al., 2018). Recent studies have targeted elementary schools with nutrition programs, suggesting that such integration could help improve the cognitive and nutritional well-being of the children – thereby enhance their likelihood of achieving their full potential as adults. However, most of the programs have not yet incorporated the preschool children as change agents with behavior change communication strategies involving their caregivers independently or simultaneously, thus a missed opportunity. In essence, while there is a developing line of studies involving the ECD institutions in the promotion of improved nutrition outcomes, the role of this phenomenon when preschool children are integrated as change agents is an essential gap in literature. Therefore, exploring the evidence base on effective ways to scale-up the biofortified technologies (OFSP) through ECD-centered complementary agriculture-nutrition education interventions will be necessary.
1.3 Objectives of the Study
The main objective of this study was to assess the effect of ECD-integrated complementary nutrition education approaches on the production and consumption of OFSP among preschoolers and their caregivers. The specific objectives pursued were:
1. To assess the effects of integrated nutrition education approaches on caregivers‟ knowledge, attitude and practices around OFSP.
2. To assess the effects of integrated nutrition education approaches on the replanting of OFSP among farming households after the lapse of free vines seasons.
3. To assess the effects of integrated nutrition education approaches on consumption of OFSP among preschoolers.
1.4 Research Hypotheses
1. Integrated nutrition education approaches do not improve the knowledge, attitude and practices (KAP) of caregivers regarding OFSP.
2. Integrated nutrition education approaches do not improve the likelihood of the caregivers to replant OFSP after the lapse of the free vines dissemination projects.
3. Integrated nutrition education approaches do not increase the consumption frequency of OFSP among preschoolers.
1.5 Justification
Children and women of reproductive age are the most vulnerable groups to VAD (World Health Organization, 2018). It is imperative to ensure that the interventions aimed at eradicating this type of malnutrition have a direct focus on the vulnerable group as both the change agents and primary targets of the projects and programs for desired nutrition outcomes. Recent literature strongly highlights the fact that prevalence of malnutrition within a society is not only due to insufficient access to quantity and quality food but also unreliable utilization of the same. The latter factor is heavily dependent on the production and consumption behavior of the vulnerable group. The result of this study will help the entire stakeholders in the fight against malnutrition to improve their understanding of the effectiveness of nutrition education with preschool children and their caregivers in enhancing the pathways to improved nutrition security.
The second and third sustainable development goals (SDGs) of the United Nations Development Program (UNDP) aim at eliminating poverty and hunger and ensuring sustainable health and well-being of the society. People in the rural areas of the developing countries are reported to perform relatively more poorly on the relevant indicators of economic welfare, food and nutrition security, and the general health and wellbeing of individuals (Shetty, 2018). There is, therefore, a critical need for improvement in the policies and programs that are implemented by the government and development partners towards achieving the goals. Understanding the appropriateness of nutrition education approaches as explored in this study will help the stakeholders with effective designing, planning, and implementation of agriculture-nutrition interventions that have improved the potential of realizing the SDGs that targets eradication of hunger in all its forms.
The prevalence of malnutrition over the centuries has prompted the development and implementation of different approaches in a bid to end the menace. The appropriateness of these approaches varies with different factors, including the demographics of the target group, the financial demand and supply, and the scalability given the geographic distribution of the target.
Food-based approaches have been promoted as the best approaches for developing countries with relatively weak financial support to fund supplementation and the rural societies that cannot continuously afford to purchase the fortified industrial products. Nutrition education, on the other hand, is aimed at improving knowledge and motivating positive behavior change among the target households and individuals towards nutritionally responsive behaviors. This study combines both the food-based approach (production of biofortified crops) and nutrition education to demonstrate the unexplored potential of such integrated approaches in realization of the pathways to nutrition security. In essence, this study contributes to the literature on effective targeting and integration of nutrition education and its delivery approaches aimed at promoting sustainable adoption of food-based approaches in rural farming households.
More than 1.8 million children are chronically undernourished in Kenya. The focus of the study on improving the pathways to nutrition security is, thus, intrinsically and instrumentally significant. First, children have a constitutional right to grow-up healthy and well-nourished (Republic of Kenya, 2014). Secondly, chronic-undernutrition has long-lasting effects that persist into adulthood (especially the physical and psychological consequences of stunting). Therefore, it is imperative to instill fundamental knowledge of good nutritional practices among the young generation.
Malnutrition in general poses a significant burden in economic and social development of individuals and the nation at large. Kenya lost a total of Kshs 373.9 billion (6.9 percent of GDP) in 2014 as the total effect of child undernutrition on health, education and productivity (Republic of Kenya, 2019). The far-reaching effects of malnutrition on human capital, labor productivity and the overall attainment of the economic development goals, call for strategic multisectoral approaches rather than treating malnutrition as an exclusive public health problem. A focus on eradicating malnutrition has positive effects towards the attainment of critical tenets of the Kenya‟s Vision 2030, which targets to reduce stunting to 14.7 percent and underweight to 8.4 percent. It aims to secure a place for Kenya in the list of the most competitive global economies with high quality of life (Republic of Kenya, 2008). Nutrition is also a critical component of the Kenya‟s 5-year-rapid-development blue-print, the “Big 4 Agenda”, which also targets 100 percent food and nutrition security. The findings of this study will make significant contribution to inform the policy makers towards designing food and nutrition intervention approaches to achieve rapid results in nutrition security and make profound contribution to the national and global food and nutrition policies.
1.6 Study Area
The study was conducted in Homa Bay county, one of the leading producers of sweetpotato in Kenya. Also, the county was of particular interest as it hosted a large project that aimed at scaling up the production and consumption of OFSP to reduce the high incidence of malnutrition (Okello et al., 2019). More than half the population of under-2-year old children in the county are malnourished (Republic of Kenya, 2014). However, most households have a child of between 3 and 5 years old, with 76 percent enrolled in ECD centers (County Government of Homa Bay, 2018). Also, more than half the households in the county grow sweetpotato for both subsistence and commercial purposes, with women playing a significant role in the production activities (Opiyo et al., 2010). These conditions make ECD centers a good avenue for reaching out to the households with under-5-year olds with nutrition initiatives. They also make OFSP an essential vehicle for delivering vitamin A and eradicating micro-nutrient malnutrition in the county.
The county is located in the western part of Kenya and is divided into eight sub-counties; Kasipul, Ndhiwa, Kabondo-Kasipul, Rangwe, Karachuonyo, and Homa Bay Town Sub- Counties. It has an outstanding primary school net enrollment rate of 98 percent, which makes researching with children a reliable representation of the households in the periphery of the schools (NCPD, 2017). Figure 1 shows a map of the county with the specific study villages marked by location pointers in an enlarged map. The different colours of the location pointers refer to the randomization of the villages into different study groups will be discussed in the proceeding sections.
1.7 Organization of the Thesis
This thesis is organized into six chapters. The context of the study, research problem, objectives, hypotheses and justification for the study have been presented in chapter one. In chapter two, there is an in-depth issue-based review of relevant literature. Further, chapter three focuses on the assessment of changes in the caregivers' knowledge, attitude and practices due to nutrition education interventions. In chapter four, the effects of the nutrition education interventions on the retention of OFSP in the subsequent planting season are presented. Chapter five provides an analysis of the effects of the interventions on the frequency of consumption of OFSP among preschool children. Finally, chapter six presents the general summary of the main findings, conclusion of the study and recommendations to policy makers and for further research
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