No abstract

Iron and folic acid (IFA) supplementation is one of the most cost-effective interventions to prevent and treat anemia during pregnancy. Despite having the highest global burden of anemia among pregnant women, rates of IFA uptake in pregnancy in India are still very low, particularly in the state of Uttar Pradesh. While there have been several studies that explored challenges around IFA consumption and adherence, there is a paucity of studies that have synthesized this information into a single visual tool that can help program implementers understand the challenges and identify potential areas of intervention.  Timeline maps were developed as a visual qualitative tool to explore the nuances of health behaviors among pregnant women with respect to antenatal care (ANC) services, including IFA consumption.  Timeline maps were used to visually document critical events pertaining to ANC services chronologically, including details on contact points with the health system and events specific to IFA distribution, consumption and counselling.  Six research assistants (RAs) were trained on how to use timeline maps and record participant narratives. The RAs later participated in a focus group discussion to gain insight about their experiences using the tool. RAs reported that the timeline maps were easy-to-use and facilitated in-depth conversations with participants. RAs shared that they were able to actively engage the participants in co-creating the maps. The visual nature of the tool prompted participants’ recall of key pregnancy events and reflexivity. Challenges reported with the tool/process included recollection of past events and potential misrepresentation of information. These highlight a need to restructure training processes. Our findings indicate that timeline maps have the potential to be used in a variety of other program contexts, and merit further exploration.

Objectives Optimal complementary feeding (CF) practices among children 6–23 months can prevent childhood malnutrition and can improve long term development and health. Our study aimed to understand CF practices in children 6–23 months, as part of an ongoing nutrition program (with a focus on improving dietary diversity) in UP, India. Methods Mothers of children 6–23 months old were interviewed in 125 blocks across 25 districts of UP (N = 34,290). We assessed dietary intake using 24-hour dietary recalls and calculated minimum dietary diversity (MDD, 4 + food groups) and age-appropriate minimum meal frequency (MMF). We used multivariate logistic regression to test for associations between MDD and program exposure variables, such as frontline worker (FLW) CF knowledge, home visits by FLWs, and FLW counseling on age-appropriate CF practices, controlling for age, caste, religion, mother's education level, birth order and sex of the child. Results Merely 22% of children 6–8 months old received any semisolid/solid food the previous day, and even at 1 year of age, only 60% children received any CF. Fourteen % of all children and 5% of children 9–11 months received age-appropriate MMF. Children 6–23 months old had poor diets with only 11% reaching MDD. Only 3% of younger children (6–11 months) and 18% of children 12–23 months reached MDD. In children 12–23 months, starchy staples, pulses, other fruits and vegetables (F&V) and dairy products were consumed in higher proportions (65%, 52%, 36% and 36% respectively) while Vitamin-A rich F&V, eggs and flesh foods were rarely consumed (11%, 2% and 3.1% respectively). Higher odds of achieving MDD were associated with FLWs CF knowledge (OR: 3.2; 95% CI: 2.2–4.5), home visit by FLWs in the past month (OR: 1.2; 95% CI: 1.1–1.4) and counselling by FLWs on age-appropriate CF practices (OR: 1.4; 95% CI: 1.2–1.7) were positively associated with MDD. Conclusions CF practices in children 6–23 months old in these 25 districts in UP are suboptimal. Dietary diversity in this age group can be improved by improving FLW knowledge and quantity and quality of FLW interactions with families. Results suggest a need for targeted age-specific counselling to increase meal frequency and to introduce a greater variety of foods to younger children. Funding Sources Bill and Melinda Gates Foundation.

Iron and folic acid (IFA) supplementation is one of the most cost-effective interventions to prevent and treat anemia during pregnancy. Despite having the highest global burden of anemia among pregnant women, rates of IFA uptake in pregnancy in India are still very low, particularly in the state of Uttar Pradesh. Timeline maps were developed as a visual qualitative tool to explore the nuances of health behaviors among pregnant women with respect to antenatal care (ANC) services, including IFA consumption.  Timeline maps were used to elicit and visually document critical events pertaining to ANC services chronologically, including details on contact points with the health system and events specific to IFA distribution, consumption and counselling. The tool consists of a horizontal straight line with nine suspended boxes corresponding to each month of pregnancy, with legends on how to illustrate IFA receipt and consumption. In this instance, the woman’s last menstrual period and expected date of delivery were used as a frame of reference for the duration of pregnancy.  Six research assistants (RAs) were trained on how to use timeline maps to elicit and record participant narratives. The RAs later participated in a focus group discussion to gain insight about their experiences using the tool. The timeline maps were easy-to-use and facilitated in-depth conversations with participants. RAs were able to actively engage the participants in co-creating the maps. The visual nature of the tool prompted participants’ recall of key pregnancy events and reflexivity. Challenges reported with the tool/process included recollection of past events and potential misrepresentation of information. These highlight a need to restructure training processes. Our findings indicate that timeline maps have the potential to be used in a variety of other program contexts, and merit further exploration.