Type and extent of trans-disciplinary co-operation to improve food security, health and household environment in low and middle income countries: systematic review
Although linkages have been found between agricultural interventions and nutritional health, and the development of clean fuels and improved solid fuel stoves in reducing household air pollution and adverse health effects, the extent of the potential of combined household interventions to improve health, nutrition and the environment has not been investigated. A systematic review was conducted to identify the extent and type of community-based agricultural and household interventions aimed at improving food security, health and the household environment in low and middle income countries.
Methods
A systematic search of Ovid MEDLINE, PUBMED, EMBASE and SCOPUS databases was performed. Key search words were generated reflecting the “participants, interventions, comparators, outcomes and study design” approach and a comprehensive search strategy was developed following “Preferred Reporting Items for Systematic Reviews and Meta-Analyses” recommendations. Any community-based agricultural and/or household interventions were eligible for inclusion if the focus was to improve at least one of the outcome measures of interest. All relevant study designs employing any of these interventions (alone/in combination) were included if conducted in Low and middle income countries. Review articles, and clinical and occupational studies were excluded.
Results
A total of 123 studies were included and grouped into four intervention domains; agricultural (n = 27), air quality (n = 34), water quality (n = 32), and nutritional (n = 30). Most studies were conducted in Asia (39.2 %) or Africa (34.6 %) with the remaining 26.1 % in Latin America. Very few studies (n = 11) combined interventions across more than one domain. The majority of agricultural and nutritional studies were conducted in Africa and Asia, whereas the majority of interventions to improve household air quality were conducted in Latin America.
Conclusions
It is clear that very little trans-disciplinary research has been done with the majority of studies still being discipline specific. It also appears that certain low and middle income countries seem to focus on domain-specific interventions. The review emphasizes the need to develop holistic, cross-domain intervention packages. Further investigation of the data is being conducted to determine the effectiveness of these interventions and whether interdisciplinary interventions provide greater benefit than those that address single health or community problems.
Keywords
AgricultureFood securityNutritionHousehold air pollutionWater qualityInterventionHealth
Background
Although there has been a significant improvement in global food security, still 805 million people (one in eight people) in low and middle income countries (LMIC) remain chronically undernourished [1]. According to the key findings of the Global Food Security Index 2015 [2], the rate of under nutrition is considerably higher in low and lower middle income countries (25.4 % and 16.5 % respectively) compared to high income countries (4.9 %). It is also estimated that 29.1 % and 15.5 % of children under the age of five years in lower middle income countries are either stunted or underweight. The prevalence rate is even higher in low income countries where 39.1 % of children under the age of five years are stunted and 22.6 % are underweight [2].
In addition to the health effects of food insecurity leading to poor nutrition, household air pollution from combustion of solid cooking fuels such as firewood, charcoal, etc. is the fourth leading cause of mortality in LMIC [3]. Evidence from epidemiological studies have shown that exposure to household air pollution is associated with acute respiratory tract infection, chronic obstructive pulmonary disease (COPD), cataract and lung cancer [4–6]. Likewise diarrhoea and other common infectious diseases due to poor hygiene and sanitation are also causing significant public health problems in LMIC [3].
It is evident that health is a complex phenomenon determined by multiple risk factors. Complex environmental interactions make it difficult to determine pathways to health in many communities. Food and diet is clearly an important route for exposure to pathogens, but it should not be considered in isolation, since other environmental exposures, such as household air pollution due to burning of biomass for cooking, pesticide exposure from agricultural use and polluted water for drinking, can be equally or more important to health. Food insecurity leading to poor nutrient intake is the main cause of malnutrition, but it is also dependent on other immediate causes, such as the individual’s health status [7]. Previous studies have recognised strong linkages between agricultural interventions and nutritional health [8–10] and the development of clean fuels and improved solid fuel stoves in reducing household air pollution and adverse health effects [11]. However, the scale and effectiveness of combined household interventions to improve health, nutrition and the environment has not been investigated. It is unknown whether interventions are inter-disciplinary, crossing domains of health, nutrition, agriculture and/or environment and where these interventions are being conducted. This review determined the extent and types of community-based complex agricultural and household interventions to improve food security, health status and the household environment in LMIC.
Methods
Search strategy
A comprehensive search strategy was developed following the recommendations in the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) statement [12]. Key search words were generated reflecting the PICOS (participants, interventions, comparators, outcomes and study design) approach [12]. A database search of Ovid EMBASE was performed using Medical subject heading (MeSH) terms, keywords and truncations covering the potential interventions, outcomes of interest and study design (Additional file 1). The search strategy was developed by combining those search terms using appropriate Boolean operators such as AND/OR/NOT. The search strategy for Ovid MEDLINE, PUBMED and SCOPUS databases were then derived from those search terms and conducted in January 2015. In addition, web and hand searches of bibliographies of identified studies were also performed manually to identify any additional potentially eligible articles.
Study selection and inclusion criteria
Community-based agricultural and household interventions such as the introduction of biogas, improved cook stoves, home gardening, animal husbandry, livestock farming and nutrition education were eligible to be included in this study if the focus of the intervention was to improve at least one of the outcome measures of interest (Table 1). Human studies employing any of these interventions, alone or in combination, and published after 1990, were included.
Table 1
Definitions of outcomes of interest measured
Outcome categories
Outcomes of interest measured
Food production
Year round of food production, production of vitamin A- rich fruits and vegetables, poultry stock and egg production, fish production, access to goat milk and other home grown foods
Food consumption
Household food security level/score, Dietary Diversity Score (DDS), consumption of food/food groups per day
Nutrient intake
Micro- and macro-nutrient intake levels
Anthropometry
Prevalence of Stunting [Weight for age Z-score (WAZ)], Wasting [height for age Z-score (HAZ)], underweight, child growth, height and weight gain
Nutrient deficiencies
Vitamin A deficiency level, Incidence/prevalence of anaemia, serum retinol concentration, serum ferritin level, haemoglobin, night blindness
Air quality
Kitchen/household/personal exposure to carbon monoxide (CO) and/or concentration of fine particulate matter of diameter < 2.5 μm (PM2.5), kitchen smoke, suspended particulate matter (PM) concentration, nitrogen dioxide concentration, ratio of food to fuel
Health
Incidence and/or prevalence of: Diarrhoeal disease; morbidity; respiratory disease symptoms (cough, runny nose, breathlessness, incidence of chronic obstructive pulmonary diseases (COPD), pneumonia); eye irritation/infection, headache. Changes in: lung function performance; cognitive performance and attention levels; quality of life
Microbial Contamination
Thermo tolerant coliforms (TCC) count, level of E.coli contamination
Hygiene and sanitation
Kitchen and hand hygiene, behaviour and knowledge of water storage, self-reported compliance
Education
Perception and knowledge of health and nutrition
The review was open to include any interventional or observational study, such as randomised control trial (RCT), cluster-randomised trial (CRT), cross-sectional study (CSS) and longitudinal studies conducted in LMIC as defined by the World Bank list of economics for 2015. As the main focus of this study was to identify community-based household interventions, clinical and occupational studies were excluded from the review. Similarly, review articles and studies from high income countries were excluded from the review.
All articles identified by electronic searching from the four databases were exported to a web-based bibliography and database manager namely, Refworks. The titles were merged in one database and duplicates removed (Fig. 1). The primary reviewer (SG) screened titles and selected potentially relevant abstracts following predefined inclusion/exclusion criteria. Then four further reviewers (DM, SS, JK and JS) independently examined 10 % of randomly selected titles and abstracts to ensure the accuracy of title and abstract screening process. Disagreements between reviewers were resolved through discussion and checking the full text articles. All articles deemed potentially eligible were retrieved in full text. Reference lists of included studies were also checked to identify other relevant studies.
Fig. 1
PRISMA flow diagram
Data extraction and management
A standard data extraction form (Additional file 2) was designed considering the Cochrane systematic review data collection checklist [13]. The data collection form was piloted and amended prior to starting the formal data extraction.
Data from all included studies were extracted independently by three reviewers. The extracted data from 10 % of randomly selected articles was then checked independently by a second reviewer to ensure all the correct information was recorded.
Data analysis
A narrative analysis was conducted based on interventional categorisation. Interventions were categorised according to four domains defined as follows:
Agricultural interventions: Interventions such as home gardening and animal husbandry that have the explicit goal of improving food productivity, nutritional status, health, dietary diversity and/or food security.
Air quality interventions: Interventions such as improved cook stove and biogas that have the clear aim of improving household air quality and occupant’s health.
Water quality interventions: Interventions such as water filters (sand and bio sand), solar disinfection technique, water treatment using chlorine tablets alone and/or combination with sanitation health and hygiene education that have the clear aim of improving drinking water quality and health.
Nutritional interventions: Interventions such as nutrition education, complementary food and nutritional supplements that have the clear aim of improving participants’ nutritional status, dietary diversity, and health and food security.
The studies from each interventional category were summarised in tables and narrative text provided to summarise the following aspects:
country where the study was conducted
sample size
setting
study designs followed
types of interventions provided
intervention duration
outcomes of interest measured
Assessment of methodological quality
An assessment of the validity of included studies was conducted alongside the data extraction using the Effective Public Health Practice Project (EPHPP) quality assessment tool for quantitative studies [14]. Studies were categorised as strong, moderate or weak based on their quality with regards to component ratings of selection bias, study design, confounders, blinding, data collection method, withdrawals and drop-outs and analysis.
Results
Identified studies
The search retrieved 10,847 unique articles (Fig. 1). After removal of 1,638 duplicates the remaining 9,209 articles were screened on the basis of title review. The first stage selection excluded 9,072 articles on the basis of predefined exclusion criteria. Studies were mainly excluded as they were conducted in high income countries, clinical or occupational settings, were not interventional studies or review articles, etc. From these 137 articles were potentially eligible for abstract screening. Finally, 112 articles met the eligibility criteria for the detailed analysis. Of the 25 articles excluded at the abstract screening stage four of them were from high income countries, five were in a clinical setting (Cl), five involved occupational settings, four were review articles, six papers were not interventional studies, and the full text of one paper was not available. Eleven additional articles were identified by hand/web searching. Finally, a total of 123 studies were included for the final review.
Study characteristics
Of the 123 included studies in the review, 27 (21.9 %) were agricultural interventions, 34 (27.6 %) were air quality interventions, 32 (26 %) were water quality interventions and 30 (24.3 %) were nutritional interventions (Fig. 2).
Fig. 2
Overlapping intervention domains
Characteristics of agricultural interventions (n = 27)
Of the 27 studies (Table 2) reporting agricultural interventions, 14 projects promoted and supported home gardening and household food production or the improvement of the existing garden with micronutrient-rich fruit and vegetables. Six projects promoted animal husbandry, such as pig and poultry breeding, goat farming, fisheries and dairy production. Five studies observed the effectiveness of combined home gardening and nutrition education intervention. One promoted home gardening with animal husbandry and another, a combination of home gardening, animal husbandry and nutrition education.
Table 2
Characteristics of agricultural intervention studies
Study (Author and publication year)
Country
Participants (sample size, age, setting)
Study design
Intervention details (I = Intervention and C = Control)
Duration of intervention (months)
Outcome measured
Ayele Z and Peacock C; 2003
Ethiopia
210 households
CSS (Pre and post)
I: Animal husbandry: goat farming
NR
Food consumption, nutrient deficiencies
Belachew T et al. 2013
Ethiopia
2100 adolescents, 13–17 years, household
5 year Longitudinal study
I: Food production
NR
Food consumption
Bezner KR, et al. 2010
Malawi
3838 children <3 years, household
Prospective quasi- experimental study
I: Intercropping legumes and nutrition education
C: Usual practice
72
Anthropometry
Bloem MW et al. 1996
Bangladesh
7341 participants, all aged, household
Intervention study
I: Home gardening
NR
Food production
Bushamuka VN, et al. 2005
Bangladesh
2,160 households
Intervention study
I: Home gardening
C: Usual practice
NR
Food production, food consumption
Cabalda AB, et al. 2011
Philippines
200 households, participants aged 2–5 years
CSS (2 group comparison)
I: Home gardening (n = 105)
C: Without home garden (n = 95)
NR
Food consumption
Faber M, et al. 2002,
South Africa
208 participants, aged 2–5 years, community
CSS (Pre and post)
I: Home gardening and nutrition education (n = 108)
I: Production of Orange-fleshed sweet potato (OFSP) and nutritional knowledge (n = 498)
C: Usual practice (n = 243)
24
Nutrient intake, nutrient deficiencies
Miura S, et al. 2003
Philippines
152 women, household
CSS (pre and post)
I: Home gardening
NR
Food consumption
Murshed-e-Jahan K, et al. 2010
Bangladesh
NR
Intervention study
I: Training support to farmers on aquaculture
C: Usual practice
NR
Food production, food consumption
Nielsen H, et al. 2003
Bangladesh
70 households, women of reproductive age and 5–12 years old girls
Intervention study
I: Poultry production (n = 35)
C: Usual practice (n = 35)
12
Food production, food consumption
Olney DK, et al. 2009
Cambodia
500 households
CSS (Pre and post)
I: Home gardening (n = 300)
C: Usual practice (n = 200)
NR
Food consumption, anthropometry, health
Schipani S, et al. 2002
Thailand
60 children, household
Intervention study
I: Mixed home gardening (n = 30)
C: Non gardening (n = 30)
NR
Food consumption, anthropometry
Schmid M et al. 2007
India
220 participants, Child:6 to 39 months and mother > 15 years, community
CSS (pre and post)
I: Home gardening (n = 124)
C: Without home garden (96)
96
Nutrient intake
Sha KK et al. 200,
Bangladesh
1343 participants aged <24 months, households
Longitudinal study
I: Household production and availability of rice and other fresh foods e.g. Vegetables, fish, meat
NR
Food consumption, anthropometry
Smitasiri et al. 1999
Thailand
15 communities, all age
CSS (pre and post)
I: Home gardening (seed grant) and nutrition and health messages (271)
C: without home gardening (247)
Food consumption, nutrient intake
Wyatt AJ, et al. 2013
Kenya
92 households
CSS (3 group comparison)
Dairy intensification
I1: Milk production >6 l per day (n = 31)
I2: Milk production <6 l per day (n = 31)
C: No milk production (n = 30)
2
Food consumption
Yakubu A, et al. 2014
Nigeria
58 households, community
CSS (pre and post)
I: Cockerel exchange programme
NR
Food production
RCT randomised control trial, CSS cross sectional study, NR not reported
Most of the studies were either cross sectional (n = 10) or intervention studies (n = 10) with one RCT [15]. There was a wide variation of sample sizes, ranging from 58 households [16] to >10,000 participants [15]. Similarly, duration of the studies varied; from a dairy intensifying intervention in Kenya for two months [17] to a home gardening study in India for 96 months [18]. Fourteen of these studies were conducted in Asia and the other 13 in Africa. The first home gardening study was conducted in Bangladesh in 1996 [19]. Most of these studies (n = 22) were conducted in a household setting and only a few in community settings.
Nineteen of these studies examined the effect of intervention on dietary diversity and improvement in food consumption, seven on food production, seven on nutrient intake, seven on nutritional deficiencies, seven on anthropometry, three on education, two on health and two on food security.
Characteristics of air quality interventions (n = 34)
Of the 34 air quality studies (Table 3), four projects introduced biogas [13–20] as an alternative means of cooking fuel, 17 projects promoted improved cook stoves and 11 studies examined the effectiveness of improved stoves with chimney to improve the household air quality. One project evaluated the impact of improved cook stoves with solar water disinfection and hand hygiene [21], and another looked at an improved cook stove intervention with biogas fuel and solar heaters [20].
Table 3
Characteristics of air quality intervention studies
Study (Author and publication year)
Country
Participants (sample size, age, setting)
Study design
Intervention details (I = Intervention and C = Control)
Duration of intervention (months)
Outcome measured
Alexander D, et al. 2013
Bolivia
31 household
Intervention study (pre and post)
I: Improved cook stoves with chimney (Yanalo Cookstoves)
12
Air quality, health
Burwen J and Levine DI; 2012
Ghana
768 household
RCT
I: Improved cook stoves with chimney (n = 402)
C: Traditional biomass stoves (usual practice) (n = 366)
2
Air quality, health, stove usages
Chengappa C, et al. 2007
India
60, household
Paired, before and after study
I: improved cook stoves (Sukhad)
12
Air quality
Clark LM, et al. 2009
Honduras
79 participants, mean age 43.2 years, household,
CSS (pre and post)
I: Improved cook stoves with chimney (n = 38)
C: Traditional cook stoves (n = 41)
3
Air quality, health
Chowdhury Z et al. 2012
China
30 household
CSS (pre and post)
I: Improved stoves along with biogas burners and solar heaters
534 households, participants aged <4 months at baseline
RCT
I: Improved wood stove with chimney (n = 265)
C: Open wood fires (n = 253)
14
Health
Wafula EM, et al. 2000
Kenya
400 households, women aged 15–60 years and children <5 years
Intervention study (pre and post)
I: Improved cook stoves (n = 200)
C: Traditional three-stone stoves (n = 200)
120
Health
Zhou Y, et al. 2014
China
996 participants, aged > 40 years, household
CSS (comparison between 2 groups)
I: Biogas digester and improved kitchen ventilation (n = 740)
C: Traditional biomass stove (usual practice) (n = NR)
108
Air quality, health
Zuk M, et al. 2007
Mexico
53 household
CSS (pre and post)
I: Improved cook stoves (Patsari stoves)
5
Air quality
RCT randomised control trial, CSS cross sectional study, NR not reported
Most of the studies provided data either on pre and post or between group comparisons with nine randomised control trial. The sample sizes of the studies ranged from 11 [22] to 4,000 households [23]. The duration of the study also varied considerably; a Peru cook stove project lasted for 3 weeks [24], while one vented stove project in the highlands of Guatemala collected data for 48 months [23]. The majority of the studies (n = 18) were conducted in South America, nine were in Asia, with the other seven in African countries. The first cook-stove intervention study was conducted in Nepal in 1990 [25]. All of these studies were conducted in household settings.
Almost all of the studies (28 out of 34) examined the improvement in household air quality parameters such as particulate matter and carbon monoxide concentrations. Twenty studies assessed the impact of the intervention on participants’ health outcomes such as incidence of pneumonia, acute respiratory infections (ARI), conjunctivitis and lung function, and three examined the impact on food production.
Characteristics of water quality interventions (n = 32)
Of the 32 water quality intervention studies (Table 4), 12 were water filter interventions; nine were chlorine tablets/solutions interventions, seven were Solar disinfection; two were hand water pumps along with hygiene education and latrine construction interventions [26]; one was a health, hand hygiene, water quality and sanitation educational intervention [27]; one involved disinfection tablets along with sanitation and hygiene education [28]; one was a water disinfection stove [29] and one a filter along with improved cook stove [30].
Table 4
Characteristics of water quality intervention studies
Study (Author and publication year)
Country
Participants (sample size, age, setting)
Study design
Intervention details (I = Intervention and C = Control)
Duration of intervention (months)
Outcome measured
Boisson S, et al. 2010
Democratic Republic of Congo (DRC)
240 household (1,144 participants mean age 39.1 years)
RCT
I: Lifestraw family filter (n = 120 households, 546 participants)
C: Usual practice (n = 201 households, 2277 participants)
4 (20 weeks)
Microbial contamination, health
Davis J, et al. 2011
Tanzania
248 households, participants aged <5 years
Experimental field study
I: One of following 4 intervention: 1) Information on strategies to reduce water and sanitation related illness (n = 79) 2) Information as per 1 plus water quality tests (n = 84) 3) Information as per 1 plus hand-rinse test results (n = 90) 4) information as per 1 plus water and hand rinse results (n = 81)
4
Microbial contamination, hygiene and sanitation
Du Preez M, et al. 2008
Zimbabwe and South Africa
115 households, participants aged between 12 to 24 months
RCT
I: Ceramic water filter (n = 60)
C: In-house water filter (n = 58)
6
Health
Du Preez M, et al. 2010
South Africa
649 households, 6 months to 5 years, household
RCT
I: SODISa bottles to be used to provide drinking water at all times and as much as possible drink directly from the bottle (n = 297)
C: Usual practice (n = 267)
12
Microbial contamination, health
Fabiszewski de Aceituno AM, et al. 2012
Honduras
195 participants aged <5 years, household
RCT
I: Plastic Bio sand filters, a narrow mouth gallon (20 L), water jug and general education on hygiene and sanitation (n = 90 households, 532 participants)
C : Usual practice (n = 86 households, 488 participants)
10
Microbial contamination, health
Graf J, et al. 2010
Cameroon
2,193 households, participants aged <5 years
CSS (pre and post)
I: SODIS bottles for water purification
10
Health
Garrett V, et al. 2008
Kenya
555 households (960 children aged <5 years)
RCT
I: Sodium hypochlorite water disinfection solution and storage containers and hygiene and sanitation education (n = 366)
C: Usual practice (n = 189)
2 (8 weeks)
Microbial contamination, health
Habib MA, et al. 2013
Pakistan
18,244, participants, household
Cluster-RCT
I: Diarrhoea pack (two packets of low osmolality ORS, one strip of Zinc tablets, two packets of water purification sachet and a leaflet with educational materials) (n = 9,581)
C: Usual practice (n = 8,663)
12
Health
Henry FJ et al. 1990
Bangladesh
44 children, 6–23 months, community
Intervention Study
I: Latrine construction and hygiene education (n = 41)
C: Usual practice (n = 43)
6
Health
Henry FJ et al. 1990
Bangladesh
92 participants, 6–18 months, household
Intervention study
I: Hand pumps, latrine construction and hygiene education (44)
C: Hand pumps only (48)
6
Health
Lindquist ED, et. al; 2014
Bolivia
1,198 participants, household
Cluster-RCT
I1: A household level hollow fiber filter (n = 330)
C: Life skills and attitudes and family responsibility message (n = 279)
3
Health
Luby,AP, et al. 2006
Pakistan
1340 households, all age participants
RCT
I: One of following intervention: 1) diluted bleach and a water vessel provided (n = 265) 2) soap and hand washing promotion provided (n = 262) 3) flocculent disinfectant water treatment and water vessel provided (n = 262) 4) flocculent-disinfection, soap and hand washing promotion provided (n = 266)
C: Usual practice (n = 200 households; 349 children)
14
Health
Opryszko MC et al. 2010
Afghanistan
1514 households, all age participants, household
RCT
I: Multiple intervention; liquid chlorine with a water vessel (299 households), hygiene education (233 households), improved tube well (308 households) and combination of all (261 households)
C: Usual practice (n = 292)
17
Diarrhoeal incidence
Quick RE et al. 1996
Bolivia
42 household
Intervention study (pre and post)
I1: 20 l narrow mouthed water vessel and the calcium hypochlorite solution (n = 15)
I2: 20 l narrow mouthed water vessel (n = 15)
C: Usual practice (n = 12)
9 weeks
Microbial contamination,
Quick RE, et al. 1998
Bolivia
127 households
RCT
I: Water disinfection solution and storage vessels (n = 64 households, 400 individuals)
C: Usual practice (n = 63 households, 391 individuals)
8
Microbial contamination, health
Ram PK, et al. 2007
Madagascar
242 households, participants aged 0–90 year
Intervention study
I: Water chlorination tablet and Jerrycan for water storage
NR
Education and self-reported compliance
Rangel JM, et al. 2003
Guatemala
100 households
RCT
I1: Chlorine bleach and 20 l narrow mouthed water vessel (n = 20)
I2: Combined product c in narrow mouthed water vessel (n = 20)
I3: Combined product c with customised vessel (n = 20)
I4: Combined product c in traditional vessel (n = 20)
C: Traditional vessel (n = 20)
1 (4 weeks)
Microbial contamination, health
Rose A et al. 2006
India
200 children, participants aged <5 years, household
RCT
I: SODIS bottles for water purification plus diarrhoea prevention and treatment education (n = 100)
C: Diarrhoeal prevention and treatment education only (n = 100)
6
Health
Rosa G, et al. 2014
Rwanda
566 households
RCT
I: Life straw family 2.0 filter and one improved stove (Eco Zoom Dura) (n = 285)
C : Usual practice (n = 99 households, 501 participants)
6
Microbial contamination, health
Tiwari SS, et al. 2009
Kenya
59 household
RCT
I: Concrete Bio sand Filter and instruction on filter use (n = 30)
C: Usual practice (n = 29)
6
Microbial contamination, health
RCT randomised control trial, CSS cross sectional study, NR not reported, aSODIS: Solar Disinfection method, bNADCC tablets: Sodium Dichloroisocyanurate tablets, c Combined product: a product incorporating precipitation, coagulation, flocculation and chlorination technology
Most of the studies were RCT (n = 25) or intervention studies (n = 4). The sample sizes of the studies ranged from 2 [29] to 2,193 households [31] and the interventions were delivered over periods of 2 [29] to 15 [32] months. Nine studies were conducted in South America, 10 in Asia and the remaining 13 in African countries. All of these studies were conducted in household settings.
Twenty-seven of these studies looked at the impact of intervention on health especially on the incidence/prevalence of diarrhoeal diseases; 20 on microbial contaminations and water quality; two studies examined the level of knowledge and self-compliance, two investigated air quality and one hygiene and sanitation.
Characteristics of nutrition Interventions (n = 30)
Of the 30 nutrition intervention studies included in the review (Table 5), 11 studies were supplementary food and vitamin interventions, 13 nutrition education interventions, five nutrition education together with complementary food interventions, two combined interventions of nutrition education and home gardening [33, 34] and one combined package intervention of health care, nutrition education, water and sanitation [35].
Table 5
Characteristics of nutrition intervention studies
Study (Author and publication year)
Country
Participants (sample size, age, setting)
Study design
Intervention details (I = Intervention and C = Control)
I: One of following complementary fortified foods: Weanimix (W) a combination of soybeans, maize and groundnuts, Weanimix plus minerals and vitamins (WM), Weanimix plus fish powder (WF) and Koko plus fish powder (KF) (n = 208)
54 participants, aged between 5–6 years, household
RCT
I: Four different complementary milks products; Std GUM, Iso-5 GUM, Iso-5 LP GUM, Iso-2 · 5 GUM
2
Health
Siekmann JF et al. 2003
Kenya
555 participants aged between 5–14 years
RCT
I: Three supplementary foods groups: meat (n = 134), milk (n = 144) and energy (veg oil) supplied as a school snack in a maize stew (n = 148)
C: Usual practice (n = 129)
12
Food consumption, nutrient intake
Serkatini R et al. 2013
Indonesia
54 participants, aged 5–6 years, household
Cross over study
I: Four different growing up milk (GUM) products – Standard GUM, Std GUM with 5 g isomaltulose per serving (Iso-5 GUM0, Iso-5 GU with lowered protein content (Iso-5 LP GUM), Std GUM with 2.5 g isomaltulose in combination with other vitamins and minerals (Iso 2.5 GUM)
2
Health
Vitolo M R et al. 2008
Brazil
500 individuals, all age, household
RCT
I: Breastfeeding and weaning counselling and complementary foods (163 mothers baby pairs) C: No dietary advice given (234 mother-baby pairs)
6
Health
Walsh CM, et al. 2002
South Africa
815 children aged 2 to 5 years, household
Intervention study (2 groups)
I: Nutrition education plus food aid
C: Food aid only
24
Anthropometry, nutrient deficiencies
RCT randomised control trial, CSS cross sectional study, NR: Not reported
Most of the studies (n = 18) were intervention studies (pre and post or two group comparison), ten RCT, one randomised crossover study and one crossover trial. The sample sizes of the studies ranged from 42 [36] to 40,000 [37] participants. The duration of the study also varied; from a once-off nutrition counselling training [38] to a 48 months nutrition education intervention in Nicaragua [39]. Just over half of the studies (n = 16) were conducted in Asia, nine in Africa and the other six in South American countries. Majority of these studies (n = 17) were conducted in a household settings with some in community settings.
Eighteen of the nutrition intervention studies assessed the impact of intervention on nutritional status such as growth, prevalence of stunting (low height-for-age), underweight (low weight-for-age), and wasting (low weight-for-height), 10 studies assessed food consumption and dietary diversity, nine studies assessed the impact on nutrient deficiencies, eight studies looked at health status, six at nutrient intake, five at health and nutritional knowledge, two at feeding practice and one assessed food security.
Methodology quality
Of the 123 included studies, eight studies failed to provide sufficient detail to assess their methodological quality. Information of study selection, withdrawals, blinding and confounders were particularly under-reported in the majority of studies. Because of the nature of the intervention, it was assumed that no blinding was imposed in some studies and they were therefore categorised into moderate quality study. The most common methodological problems among the weak studies were in selection bias, confounders, reliability and validity of data collection tools and blinding.
Discussion
According to our knowledge, this systematic review is the first to explore the cross-domain overlapping of multidisciplinary research projects in agriculture, nutrition, air quality and water quality. It is obvious that there is a lot of work being done in this area but from this review it clear that there is variation in not only the type of intervention, study type, sample size, duration and setting, but also in the outcome measured.
Although a wide variety of agricultural interventions such as home gardening and animal husbandry were conducted to improve household food productivity and food consumption, this review also confirms the findings of previous reviews that only few studies were measuring the impact of those interventions on nutritional status [8–10]. Of those projects that did look at the impact of agricultural intervention on nutrition, seven examined the impact on nutrient intake, nutrient deficiencies and anthropometry. In general it is predictable that increased production and consumption of food leads to better nutrition, but due to variation in study design, duration and outcome of interest measured among the included studies, it doesn’t look likely to obtain pooled estimate for studies which look at impact of intervention on nutritional health.
While looking at the air quality interventions, it is evident that interventions to improve cook stoves are the most popular interventions (83 %) and are widely being used in all over the world. This may provide the enough roofs to perform the meta-analysis. Some biogas interventions (n = 4) [20, 40–42] have been conducted to measure the multiple benefits of intervention on indoor air quality and food production (using bio-slurry). However, as they refer to different outcome measures and are measured in different ways, the available evidence does not look strong enough to perform the comprehensive analysis.
It was identified that water purification filter interventions were the most popular (n = 12) interventions for treatment of drinking water quality in LMIC. Other interventions such as chlorine tablets or solution (n = 9) and solar disinfection (n = 7) are also common in this region. Randomised controlled trial study design was the most popular among the water quality intervention as the vast majority (78 %) of the research project applied this method. So, it is more likely that effects on the drinking water quality can be summarised across studies.
Nutrition education (n = 13) and supplementary food and vitamin (n = 11) interventions were the most popular nutritional intervention in LMIC. Some intra-domain combined interventions of nutrition education and supplementary foods (n = 5) have also been piloted in some low and middle income countries to determine the impact of intervention on dietary diversity and nutrient intake.
The main finding of this review is that the vast majority (91 %) of the academic research on agricultural, nutrition and the environmental studies are simple and discipline specific with substantially fewer (n = 11) combined interventions across domains and the result is consistent with previous domain specific reviews [7, 43]. Only six studies looked at the combined impact of agricultural and nutrition education interventions, three on air and water quality interventions, one study examined the impact of a combination of agricultural and air quality interventions and one was a combined water quality and nutritional intervention. Although poor nutrition and household air pollution are the leading cause of mortality in LMIC [3], this review did not find any studies examining the impact of a combination of air quality and nutritional interventions on health. It is also striking that none of these studies investigating the combined impact of agricultural and drinking water quality interventions on human health. The evidence reviewed here shows that silo mentality is still inherent in academic research.
Another interesting finding of this review is that certain LMIC regions seem to focus on domain-specific interventions, with most studies in Kenya and India and only a small number in other countries (Fig. 3). Asian and African countries were the most common regional target for agricultural and nutritional studies. More than half of the agricultural (52 %) and nutritional (53 %) interventions were conducted in Asian countries with the majority of them in south Asian countries. Similarly, 48 % of agricultural and 30 % of nutritional studies were conducted in Africa with the majority of them focussed in sub-Saharan African countries such as Kenya, Ethiopia and South Africa. The majority of water quality interventions were conducted in Africa (40.6 %) followed by Asia (31.3 %) and Latin America (28.1 %). However, the majority (53 %) of interventions to improve household air quality were conducted in Latin American countries particularly in Guatemala, Peru and Mexico. This restricts the generalisability of the findings to other LMIC.
Fig. 3
Global map highlighting the regional focus of included studies
Strengths and limitations of the study
The main strength of this review is the application of a comprehensive search strategy through four databases to capture all potentially relevant peer reviewed articles. One hundred and twenty three articles representing the four different intervention domains provide ample evidence to understand the current research gap in interdisciplinary research. The use of independent reviewers throughout the review process further strengthened the methodological quality.
The main limitation of this study is that as only peer reviewed journal articles were included in this review, there is a chance of missing those studies published in developmental organisations’ reports and bulletins (publication bias). Additionally, this review focused on household and community-based studies, so there is a chance of missing some useful studies conducted in clinical settings.
Conclusion
In conclusion, it is evident that very little interdisciplinary research has been conducted with the majority of studies on agriculture, nutrition and the environment being discipline specific. It also seems that certain LMIC regions seem to focus on domain-specific interventions. Although a wide variety of study designs have been implemented to measure the impact of agricultural, nutrition and air quality interventions on respective outcomes of interest measured, there is still not sufficient evidence which utilises robust randomised or quasi-experimental study design.
Therefore, this review emphasizes that future research needs to focus on multi-disciplinary complex interventions with standardised outcome measures. Also, rigorous research across disciplines and sharing expertise across regions is a necessity. The next phase of this review (Meta-analysis) will identify whether eliminating silos of discipline specific research can bring a significant improvement or not.
Abbreviations
ARI:
Acute respiratory infections
C:
Control group
CO:
Carbon monoxide
COPD:
Chronic obstructive pulmonary disease
CRT:
Cluster-randomised trial
CSS:
Cross-sectional study
DDS:
Dietary diversity score
HAZ:
Height for age Z-score
I:
Intervention group
LMIC:
Low and middle income countries
MeSH:
Medical subject heading
NADCC tablets:
Sodium dichloroisocyanurate tablets
NR:
Not reported
PICOS:
Participants, interventions, comparators, outcomes and study design
PM2.5:
Fine particulate matter of diameter < 2.5 μm
PRISMA:
Preferred reporting items for systematic reviews and meta-analyses
RCT:
Rrandomised control trial
SODIS:
Solar disinfection method
TCC:
Thermo tolerant coliforms
WAZ:
Weight for age Z-score
Declarations
Acknowledgements
We are grateful to Dr Steve Turner and Dr Adam Price for their insightful comments that improved the manuscript. We would like to thank Heather Clark and Bimbola Kalejaiye for their help in data extraction. We are also grateful to Melanie Bickerton and Dr Amudha Poobalan for their systematic review advice.
Funding
The authors have no financial relationships relevant to this article to disclose.
Availability of data and materials
The datasets supporting the conclusions of this article are included within the article and its additional files.
Authors’ contributions
SG drafted the study protocol, conducted the systematic review and wrote the manuscript. JK, SS, JS, MS and DM contributed to search strategy, assessed the quality of the data extraction process and contributed to the analysis plan and authorship of the manuscript. All authors read and approved the final manuscript.
Competing interests
The authors declare that they have no competing interests.
Consent for publication
Not applicable.
Ethics approval and consent to participate
Not applicable.
Open AccessThis article is distributed under the terms of the Creative Commons Attribution 4.0 International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated.
Authors’ Affiliations
(1)
Division of Applied Health Sciences, University of Aberdeen
(2)
School of Biological Sciences, University of Aberdeen
(3)
Save the Children
(4)
WMS- Health Education, The University of Warwick
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