Child undernutrition in Cambodia is a persistent public health problem requiring lowcost and scalable solutions. Rising cellphone use in low-resource settings represents an opportunity to replace in-person counselling visits with phone calls; however, questions remain on relative effectiveness. Our objective was to evaluate the impact of two options for delivering a World Vision infant and young child feeding (IYCF) counselling programme: (1) traditional Positive Deviance/Hearth (PDH) programme with in-person visits or (2) PDH with Interactive Voice Calling (PDH-IVC) which integrates phone calls to replace 62.5% of face-to-face interaction between caregivers and volunteers, compared to the standard of care (SOC). We conducted a longitudinal cluster-randomised controlled trial in 361 children 6-23 months. We used an adjusted difference-in-difference approach using baseline, midline (3 months) and endline (12 months) surveys to evaluate the impact on child growth among the three groups. At baseline, nearly a third of children were underweight, and over half were food insecure. At midline the PDH group and the PDH-IVC groups had improved weight-for-age z-scores (0.13 DID, p = 0.011; 0.13 DID, p = 0.02, respectively) and weight-for-height z-score (0.16 DID, p = 0.038; 0.24 DID, p = 0.002), relative to SOC. There were no differences in child height-for-age z-scores. At endline, the impact was sustained only in the PDH-IVC group for weight-for-age z-score (0.14 DID, p = 0.049), and the prevalence of underweight declined by 12.8 percentage points (p = 0.036), relative to SOC. Integration of phone-based IYCF counselling is a potentially promising solution to reduce the burden of in-person visits; however, the modest improvements suggest the need to combine it with other strategies to improve child nutrition.

Objective: To examine the difference in the rehabilitation rate from underweight by child age at enrolment in the Positive Deviance (PD)/Hearth programme. Design: This secondary data analysis used programme monitoring records of underweight children aged 6–60 months attending a 2-week PD/Hearth session and followed up for 6 months in Sep. 2018–Mar. 2019. Data were analysed using multi-level mixed-effect regression and poisson regression with robust variance. Setting: Rajshahi Division, Bangladesh Participants: A total of 5,227 underweight (weight-for-age z-score [WAZ]<-2) children who attended the PD/Hearth sessions. Results: From enrolment to six months follow-up, the mean WAZ improved from −2.80 to −2.09, and the percentage of underweight children decreased to 54.5%. Compared to the enrolment age of 6-11 months, the estimated monthly change in WAZ at six months of follow-up were 0.05 lower for 12-23 months, 0.06 lower for 24-35 months, and 0.09 lower for 36-60 months of the enrolment age (all p<0.001). The probability of rehabilitation at six months of follow-up were lower by 16.7% for 12-23 months (RR=0.83; 95% CI: 0.77, 0.91), 15.5% for 24-35 months (RR=0.84; 95% CI: 0.78, 0.92), and 34.9% for 36-60 months of the enrolment age (RR=0.65; 95% CI: 0.59, 0.72), compared to the enrolment age of 6-11 months. Conclusions: Enrolment in the PD/Hearth programme at a younger age had the advantage of greater rehabilitation from underweight than older age. Our findings provide a better understanding of the successes and failures of the PD/Hearth programme to achieve more sustainable and cost-effective impacts.

Background Positive Deviance/Hearth (PDH) is an internationally recognized nutrition rehabilitation program. However, nutritional improvements are inconsistent across contexts. It is unclear if variations are from differences in program design, implementation, utilization, or other contextual factors. Furthermore, few PDH programs have addressed the high time- and work-burden of caregivers and volunteers. To address this, the study integrated interactive voice calls (IVC) with PDH. Objectives A program impact pathway (PIP) analysis was used to evaluate the secondary outcomes of facilitators, barriers, and contextual factors that influence PDH-IVC design, implementation, and utilization to improve the nutritional status of children in Cambodia. Methods The study was registered at clinicaltrials.gov[NCT03399058]. A PIP analysis was done on data collected through in-depth interviews with caregivers (n = 32), key informant interviews with volunteers (n = 16) and project staff (n = 3), and surveys of project staff (n = 5). Results In design phase, facilitators included quality training, technical support and design tools, community mobilization, and linkage to existing health services. Barriers included poor community mobilization. For the implementation phase, facilitators were good volunteer knowledge, follow-up tools and guidance, supervision, and spot checks of volunteers. Barriers were lack of time and overworked, older caregivers. For the utilization phase, facilitators included family and volunteer support and access to phones while barriers were lack of support, time, and financial resources, low levels of education and old age of caregivers, and inconsistent phone use. Contextual factors included food insecurity and increased childcare responsibilities on grandmothers due to migration of mothers. Conclusions The PIP analysis identified facilitators, barriers, and contextual factors that may affect the design, intervention, and utilization and elements to consider when designing and implementing IVC interventions for health and nutrition behavior change. When implementing child nutrition programs in Cambodia, supporting interventions addressing mental health and time and resource constraints of elderly caregivers should also be included.

Objectives The Household Food Insecurity Access Scale (HFIAS) is widely used though it has limited cross-cultural applicability. Among families with underweight children in three Cambodian districts, the HFIAS-derived prevalence of moderate/severe food insecurity was about 45%, though interviewers reported that caregivers have difficulty understanding the questions.This study seeks to develop a locally appropriate tool for measuring household food security in Cambodia. Methods Caregivers of children ages 6–24 months were screened using the Household Hunger Scale. Following Coping Strategies Index (CSI) guidance, three focus group discussions (FGD) were held with 25 food insecure caregivers from 10 villages. Participants developed a list of coping strategies in response to the question, “What do you do when you do not have enough food, and do not have enough money to buy food?” By consensus, participants weighted coping strategies in order of increasing severity. Strategies were assessed for inclusion using CSI criteria. The research and local teams combined the three lists into a single tool maintaining much of the local vocabulary. Results FGD 1 identified 16 coping strategies: one was excluded because it could not be done readily, and two were combined. FGD 2 identified 16: one was excluded because it was not repeatable, and four were combined into two. FGD 3 identified 19: six were combined into three. Seven strategies were identified in all three FGDs and seven were identified in two FGDs. Four strategies were identified in only one FGD. The resulting index is comprised of 18 coping strategies. Three strategies were weighted least severe (1). Example: “Eat rice without fish or meat.” Seven were weighted somewhat severe (2). Example: “Make food last longer by eating smaller portions and keeping it for longer than intended.” Five were weighted as more severe (3). Example: “Sell or consume seed stock held for next season.” Three strategies were weighted as most severe (4). Example: “Borrow rice or money from a lender or employer with high interest.” Conclusions Context-specific coping strategies may be useful in measuring food security in Cambodia. Future research is needed to examine the validity of this tool in comparison to established food insecurity experiences scales. Funding Sources World Vision Hong Kong. Supporting Tables, Images and/or Graphs