This study shows how a model of intersectoral intervention, to which a group of children under 1 year of age was exposed for 10 months, was able to change the nutritional status, as measured by anthropometry, i.e., L/A indicator, in 43.14% of the participants undergoing the intervention. Four children out ten moved positively in their growth trajectory; these results were based on final post-intervention measurements.
After the intervention, 4.52% of the children changed their nutritional status from chronic malnutrition to adequate length for age. These findings, when contrasted with the scientific evidence on health and nutrition interventions focused on reducing the delay in length in children under 5 years, are relevant because it has been described that those interventions of greater efficacy to reduce the prevalence of delay in length in children under 5 years are those that at least obtained a 3.0% change in the prevalence of length delay in the intervened population, with an exposure greater than or equal to 12 months [13] . In Bangladesh, CARE’s SHOUHARDO project, a nutrition intervention that links work with poverty and gender inequalities, achieved a 4.5 percentage point reduction in stunting in children aged 6–24 months [14].
In Amhara Ethiopia, an intervention (Child Caring Practices) was developed between 2004 and 2009 that included four components [1]: health [2], nutrition education [3], water [4], sanitation and hygiene, finding a 12.1% decrease in the prevalence of chronic malnutrition [15]. In Mexico, the “Oportunidades” conditional cash transfer program focused on providing fortified food, cash transfers, curative health services, and other benefits, it found children in intervention families aged less than 6 months grew 1.5 cm taller than children in comparison group families [16]. Also, a 10-year multisectoral intervention in sub-Saharan Africa, which included interventions in agriculture, health, education, and infrastructure, found that after 3 years the prevalence of chronic malnutrition in children under two was 43% lower than at the start of the program [17].
In respect to the magnitude of the change, the probability of length recovery was lower the older the age of the child. This result confirms, as several studies have described, the importance of implementing specific interventions on length delay during the most effective window of opportunity, that is, from gestation through the first 2 years of life [1, 18, 19].
The likelihood of approaching or entering an adequate growth trajectory after the intervention was found to increase when the child was in a female-headed household. A possible explanation for this result is provided by a study that argues that empowered mothers (through the female head of household, for example) have fewer time constraints to devote to their children, as well as having better mental health and more control over children and household resources, higher self-esteem, and better information and access to health services. This implies that empowered mothers take better care of themselves and their children, which is expected to have benefits for their children’s nutritional status [20].
Similarly, it has been shown that interventions that include timely education for caregivers for the age and current condition of the children, systematic monitoring, effective connection with health care and other sectors related to early childhood care, including basic sanitation and drinking water, developed in low- and middle-income countries are more effective for better outcomes related to child nutrition [13].
For example, at the end of the intervention, 80.9% beneficiary families had their comprehensive assessment of growth and development cards for their children and were able to explain their importance; their use demonstrates caregiver empowerment through exercising their rights and duties as citizens, benefiting them as a community. Necessary conditions for caregivers to effectively access health care relevant to the age of their children are key factors for the prevention and/or management of delayed length in the window of opportunity of early childhood [1].
It is necessary to mention that the educational strategy used for the intervention axis was counselling, whose principle is to work on the basis of the needs expressed by those who will be the subjects of the education using the skills that allow improving the communication process between the facilitators and the participants so that they acquire the necessary skills for informed decision making [21].
In this study, at the end of the intervention, seven out of ten children continued breastfeeding (73.7%) as part of their eating pattern; in comparison with the breastfeeding practice at baseline, improvement in practice was evident. Evidence has shown that using counselling contributes positively to practices related to the duration of exclusive and continued breastfeeding [22]. In agreement, a study identifying common breastfeeding problems in the postpartum period found that 98.3% of mothers considered breastfeeding education necessary [23].
Similarly, an improvement in the general practice of breastfeeding has been related as a function of maternal educational level and to mothers being immersed in protective environments and surrounded by community supporters [24]. These elements were also observed; most of the mothers had completed their high school education and a significant proportion, by the end of the intervention, had completed higher technical studies, a finding that suggests the importance of consolidating intersectoral strategies to favour the formal education of mothers and caregivers.
The probability of approaching or being in the appropriate growth trajectory, after the intervention, was reduced if the children were fed with formula milk compared to those who did not receive it. This result is consistent with other studies. A study conducted in public hospitals in Hong Kong found for a sample of 642 preterm children with low weight, those fed during their hospitalization with breast milk had a better z-score for length-for-age upon discharge than children fed formula milk because children fed formula have a higher risk of gastrointestinal infections that affect weight and length [25].
These results reaffirm breast milk providing nutrients children need for healthy growth and development during their first 2 years and beyond; therefore, it is necessary that social programs have as a priority the promotion and protection of this practice, as established by the WHO: exclusive breastfeeding during the first 6 months of life and adequate complementary feeding until 2 years or more [26].
According to the age of the children, 29.2% consumed eggs at baseline (older than 6 months), and 83.32% consumed eggs at the post-intervention measurement. That is, eight out of ten children were eating eggs as one of their main sources of protein. After the intervention, nine out of ten children (90.21%) had food sources of animal protein as part of their eating pattern. This result could be related to food voucher delivery, part of the social focus of the intervention model.
These vouchers were redeemed monthly by each beneficiary family in the study in a local supermarket. The redemption had a list of foods that included healthy food. This list was defined taking into account the recommendations for feeding for early childhood defined by the governing body of the sector for Colombia, ICBF [27]. Additionally, the proposed form of redemption favoured families having autonomy in decision-making for the purchase and preparation of food. This was mediated by the collaboration between the axes of education for caregivers and social care.
According to the evidence, the way to effectively intervene in length delays in early childhood requires comprehensive intersectoral work that encompasses cross-cutting actions that can account for most of the determinants of this condition, as the intervention developed in this study [19].
In relation to the sociodemographic results:
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1.
Family income plays a fundamental role in the recovery of stunting. A World Bank study argues that the link between income and nutritional status occurs mainly because households with higher income levels can invest more in consumption and variety of foods, in addition to having better quality of services and more resources to invest in the care of their children [28]. This relationship has been validated by different studies using different measures to determine income as monthly wages [28, 29] or assets in the home [30], among others.
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2.
The results obtained in the model in terms of the mother’s level of education were not consistent with the scientific evidence. Different authors have reported that children of more educated mothers have better results for the nutritional indicator length-for-age [2, 19, 31]. Education empowers women to make decisions that they would not be able to make in the absence of education, such as having fewer children or using health services more appropriately, leading to better physical and emotional development of their children [25, 32]. This relationship was not evident in the present study.
The intervention model implemented in the study is in line with several of the recommendations suggested by authors such as Butta et al., who refers to following effective actions in public health that make it possible to reduce length delays when implemented during early childhood: (i) folic acid supplementation in the preconception period; (ii) dietary supplementation to obtain a positive energy and protein balance in pregnant women; (iii) calcium supplementation for mothers; (iv) multiple micronutrient supplementation during pregnancy; (v) promotion of breastfeeding; (vi) adequate complementary feeding; (vii) administration of vitamin A; (viii) preventive zinc supplementation in children from six to 59 months; (ix) treatment of moderate acute malnutrition; and (x) treatment of severe acute malnutrition [33].
Limitations
The sampling for this study was consecutive, and families were recruited mainly by mass communication strategies and the “snowball” technique. This sample determination did not allow us to extrapolate the results to the entire population of Bogotá. The intervention model developed and the results of the study directly pertain to the specific composition of the sample, mainly in terms of socioeconomic indicators; therefore, the magnitude of the change obtained in the Length/Age indicator for the beneficiaries of the study is specific to this group of children under the conditions that were treated.