The Effects of Community Home Visit and Peer Group Nutrition Intervention Delivery Platforms on Nutrition Outcomes in Low and Middle-Income Countries: A Systematic Review and Meta-Analysis

"...findings underscore the importance of interpersonal community platforms for improving infant and young child feeding practices and children’s nutritional status in LMICs."

Emerging evidence indicates that preventing the adverse effects of undernutrition requires programmes that enhance the coverage and effectiveness of direct nutrition interventions, particularly those focused on actions during the first 1,000 days of life. This paper synthesises evidence for the effectiveness of nutrition-specific intervention delivery platforms for improving nutrition outcomes in low and middle-income countries (LMICs).

A systematic literature search for studies published from 1997 to June 2018 resulted in the inclusion of 83 randomised controlled trials (RCTs), quasi-randomised, and controlled before–after studies across a variety of delivery platforms. (All included studies used an experimental design, though the overall quality of evidence was low for the majority of meta-analysed outcomes.) Though the reviewed studies covered community-, financial- and technology-based nutrition intervention delivery platforms, this paper reports only on meta-analysed outcomes for community health worker (CHW)/lay counselor home visits and mother/peer groups, which emerged as the most widely used community-based platforms for delivering nutrition-specific interventions in the review. These studies utilised one or both of these platforms to deliver nutrition education/behaviour change communication (BCC) to mothers/caregivers of young children.

Compared to care as usual, CHW home visits increased early initiation of breastfeeding (EIBF) (odds ratio (OR): 1.50; 95% confidence interval (CI): 1.12, 1.99; n = 10 RCTs) and exclusive breastfeeding (EBF) (OR: 4.42; 95% CI: 2.28, 8.56; n = 9 RCTs). Mother/peer groups were effective for improving children's minimum dietary diversity (OR: 2.34; 95% CI: 1.17, 4.70; n = 4) and minimum meal frequency (OR: 2.31; 95% CI: 1.61, 3.31; n = 3). Pooled estimates from studies using both home visit and group platforms showed positive results for EIBF (OR: 2.13; 95% CI: 1.12, 4.05; n = 9) and EBF (OR: 2.43; 95% CI: 1.70, 3.46; n = 12). A 23% reduction in the odds of under-5 wasting (OR: 0.77; 95% CI: 0.67, 0.89) was observed across four studies that used the home visit and group platform, compared to usual care.

Reflecting on the findings, the researchers note, for example:

• The lack of effect of the mother/peer group platform on breastfeeding in the review was unexpected and may have been due to differences in programme factors across studies, e.g., the frequency, content, and facilitation of group sessions. The review was not able to separate the effects of using trained CHWs versus peer volunteer facilitators for conducting group sessions. Further research should explore whether facilitator characteristics may affect programme targets.
• The higher likelihood of EIBF and EBF in pooled analyses of studies involving both home visit and mother/peer group platforms suggests that home visits are important for breastfeeding promotion. The researchers speculate that this finding is due to the one-to-one reinforcement of knowledge and skills acquired in group sessions and/or mothers feeling more comfortable discussing and practicing breastfeeding in the privacy of home settings.
• The finding that the mother/peer group platform is effective for improving the quantity and quality of young children's diets may be due, in part, to participatory cooking demonstrations that frequently occur alongside counseling/coaching during group sessions. This finding is consistent with a 2018 review of 36 studies that showed that women's groups focused on behaviour change are beneficial for improving child feeding practices in South Asia.
• The observed 23% reduction in the odds of under-5 wasting using the combined home visit and group platform and suggests acute thinness may be more responsive to education/behaviour change interventions than the long-term nutritional deficits underlying stunting.

As community home visits and peer groups "tend to be established platforms within community-based child survival programmes in many countries, leveraging them for integrating nutrition-focused interventions...offers sizeable opportunities for nutrition behaviour change in these settings. Therefore, the findings present an evidence-based rationale for continued investments in these community initiatives."