Scaled-Up Nutrition Education on Pulse-Cereal Complementary Food in Ethiopia: A Cluster-Randomized Trial

Background Improving children's weight status through nutrition education (NE) for mothers about using pulses in complementary feeding has been demonstrated in pilot studies, but no effect on stunting was reported. The aim of the study was to evaluate the effectiveness of a 9-month pulse-nutrition education program on mothers' knowledge, attitude, and practices (KAP) towards pulses, as well as its impact on children's dietary diversity, and nutritional status. The NE was delivered by Health Extension Workers (HEWs). Methods A cluster randomized study was employed for the community-based interventional study. Twelve randomly selected villages in Sidama Zone, Southern Ethiopia were included in the study. A total of 772 mother-child pairs involved in the study; where 386 mother-child pairs in the intervention group received additional messages about pulse-cereal complementary food, and 386 pairs (the control) received only routine health education for 9 months. A survey on mothers’ KAP and anthropometric measurements of the children were taken at baseline, midline, and endline. Results At baseline and endline, maternal KAP and the dietary diversity score of the children (mean age at endline 18.8 ± 2.9 mo) were assessed. Results : Intervention mothers’ KAP improved ( p <0.001) at midline and endline compared to that of the control group, as did frequency of pulse consumption and DDS among children. At 9 months, the prevalence of stunting, wasting, and underweight was significantly reduced in the intervention group compared to the control group ( p =0.001). Conclusions NE delivered by HEWs improved KAP of mothers regarding pulse consumption and dietary diversity of children led to improved nutritional status of the children. Training HEWs on the use of pulses for CF may be an effective way to improve the health of children in Ethiopian communities.


Background
Undernutrition in the first 1000 days is responsible for the annual death worldwide of over 3 million children under five years of age, and poor complementary feeding is one reason for undernutrition [1]. In Ethiopia, the prevalence of underweight, stunting, and wasting in children under five years of age is 24%, 38%, and 10% respectively [2]. Similar rates are found in the Southern Nations and Nationalities People Region (SNNPR) [2], the least urbanized region of the country (90% rural), where almost one in four live under the poverty line [3].
Exclusive breastfeeding is recommended for the first six months of a child's life, followed by the introduction of complementary foods with continued breast-feeding. If complementary foods are insufficient in quality and/or quantity, nutritional deficiencies are at high risk of developing during the second half of infancy [4]. In Ethiopia, most complementary foods are made from unfortified cerealbased gruels [2,5,6], which are low in energy and nutrient density, leading to inadequacies of many nutrients including protein, iron, and zinc [7]. Indeed, in a 2016 Ethiopian survey, only 14% of children aged 6-23 months were found to consumed food from four or more food groups, and only 45% were fed the minimum acceptable diet [2]. In SNNPR, these rates were 12.5% and 41.9%, respectively [2].
In 2004, the Government of Ethiopia introduced the Health Extension Program with the aim of improving primary health services. Four years later, the National Nutrition Program (NNP) to address the growing concern of malnutrition among children under 5 years of age was introduced. A second NNP launched in 2016 emphasized the involvement of Health Extension Workers (HEWs) in the implementation of the program. HEWs are female high school graduates from the local community who speak the local language. As part of their job description, HEWs are mandated to provide nutrition education for mothers about essential child feeding practices [8,9].
Pulses are important crops, providing high quality protein when blended with cereal [10]. They are also good sources of iron, zinc, and other important micronutrients when processed appropriately, which also improves protein digestibility [11,12]. However, in Ethiopia, only 26% of children aged 6-24 months consume pulses. In SNNPR, although pulse crops are locally grown and available, only 9% of the population consumes pulses [13]. One of the major problems encountered in addressing malnutrition is lack of knowledge among mothers, family members, and health workers about the benefits of pulses for young children [4]. Previous pilot studies have shown that nutrition education on pulses improved the knowledge, attitude, and practice (KAP) of mothers in child feeding, and that nutrient intake and some parameters of growth improved [15,16]. However, little is known about the effectiveness and sustainability of a nutrition education program conducted through the regular activities of the HEWs. The main objective of the study was to assess the effectiveness of nutrition education on pulse-incorporated complementary food to the wider rural community through the government health system to improve maternal KAP, dietary diversity, and the nutritional status of children (6 to 24 months). The hypothesis was that nutrition education would improve mothers' KAP of pulse-incorporated complementary food and subsequently would improve nutritional status, and dietary diversity of their young children.

Study Setting and Participants
This study was registered as Clinicaltrials.gov #NCT02638571, and the protocol, along with baseline results, have been published [1]. Briefly, this cluster-randomized intervention trial for communitybased nutrition education was done in 12 kebeles/villages, selected from two districts of the Sidama Zone, Southern Ethiopia. Kebeles were randomly assigned to the intervention and control groups after stratification by districts using the lottery method, as the prevalence of child malnutrition and number of children was different in each district. However, the study was not blinded, because the districts were far apart (it was not possible to walk between kebeles and back in one day), did not share markets, health centers, and health posts, and study personnel did not overlap between areas.

The Intervention and Education Materials
Key messages were developed based on the Theory of Planned Behaviour (TPB) and Health Belief Model (HBM) principles [17,18]. Health Extension Workers, two of whom were located in each kebele, were provided with nine months of additional nutrition education, along with the usual health education. The HEWs provided the mothers in the intervention group with five main lessons. An intervention with recipe demonstrations on preparation of porridge for complementary feeding using germinated pulse and cereal was given once a month and repeated again after midline (4.5 month) data collection. In addition, participating mothers in the intervention group were counseled by HEWs during house-to-house visits. The additional messages delivered to the intervention group were not included in the usual health education delivered to the control group. The control group received the usual health education provided in the area, which is mainly based on the essential nutrition action messages.
A Training of Trainer (TOT) manual was mainly used to train HEWs. This manual was developed and used by the Canadian International Food Security Research Fund (CIFSRF) for the "Scaling-up Pulse Innovations for Food and Nutrition Security" project [19]. Key messages included in the TOT manual were the importance of consuming food from all food groups and dietary diversification; the benefits of pulses; household pulse processing and preparation techniques, and the need to prepare and cook a variety of pulse-based dishes, including pulse-cereal mix complementary food. HEWs were trained for three days with demonstrations. At the same time, HEWs in the intervention group had refresher training in communication and counseling skills. In addition, HEWs were trained to use a quick guide when counseling mothers during house-to-house visits [20]. In the control sites, HEWs continued to provide routine health education. These HEWs had not been specially trained in using pulses in complementary food.
Before the intervention was introduced, the training material and counseling poster were pre-tested on purposively selected mothers to assess whether the content and format were realistic, understandable, culturally appropriate, visually appealing, and motivating. These mothers from the Hawassa Zuria district, who did not participate in the actual study, were provided with a half-day education and their understanding of the messages was assessed through discussion. Each picture on the poster was also assessed for its cultural acceptance.
The KAP of mothers regarding pulse consumption and feeding practices were collected at the baseline, midline, and endline of the intervention period. A standardized questionnaire was used to assess the mothers' intentions to use cereal-pulse incorporated complementary food. Theory of Planned Behavior [18] and the Health Belief Model (HBM) was used to frame questions to assess the KAP of mothers based on the guidelines of Macias and Glasauer [17].

Dietary Diversity and Growth Assessment
Using a structured questionnaire, the mothers were asked about the type and number of meals consumed by their young children in the previous 24 hours [21]. In addition, the Dietary Diversity Score (DDS) for each child was calculated based on the World Health Organizations (WHO) guidelines for measuring individual dietary diversity scores, using the following food groups to calculate the DDS: 1) grains, roots, and tubers; 2) legumes and nuts; 3) dairy products (milk, yogurt, cheese); 4) flesh foods (meat, fish, poultry, and liver/organ meats); 5) eggs; 6) vitamin-A rich fruits and vegetables; and 7) other fruits and vegetables [22]. A sum of the total number of food groups consumed was calculated for each child, and the proportion of children consuming four or more food groups per day was determined. In addition to the number of meals, the frequency of the children's pulse consumption was assessed using a frequency questionnaire to evaluate monthly consumption of pulses.
The anthropometry of the children was taken at baseline, midline, and endline using standardized techniques [23]. In brief, weight was measured using an electronic scale (Seca 770), and the children were draped in a light cloth of known weight during the measurement. The recumbent length was measured to the nearest 0.1 cm using the Shorr measuring board. The Middle Upper Arm Circumference (MUAC) of the left arm of young children was measured using arm circumference insertion tape. All anthropometric measurements were entered and analyzed using WHOAnthro

Assessment of Socio-Demographic Characteristics
Data on the socio-demographic characteristics of the participants, including those of the participants' household, such as age, gender, ethnicity, income, and KAP of mothers, were assessed using a standard questionnaire adopted from previous studies [15,24] with modifications. To assess the food insecurity of the households in the study area, a standardized questionnaire adapted from Food and Nutrition Technical Assistance (FANTA), the "Household Food Insecurity Access Scale," was used [25].
As suggested by [26], only the last three questions of the nine included to analyze food insecurity.
These questions have been validated in low-income countries to measure household hunger. These three questions comprise the Household Hunger Scale (HHS). Food insecurity was assessed with a recall period of the last four weeks (30 days) prior to the data collection.
Household wealth status was measured by an asset-based (non-monetary) wealth index adopted from CSA [2]. During data collection, each participating household reported assets owned and other housing and sanitation-related characteristics. These included ownership of a radio, TV, mobile phone, TV, and bicycle, access to electricity, and quantity of livestock, land size, and level of income. Housing characteristics used in the wealth index calculation include the dwelling's structure, number of rooms and bedrooms, and ownership (whether it is privately owned or rented). Each household received a score of 1 or 0 depending on whether it had the particular asset (1 = yes and 0 = No). Each binary variable was then weighted by the inverse of the proportion of households that owned the particular item or had the particular characteristics [27].

Haricot Beans for Women's Empowerment in Household Decision Making
Researchers associated with the larger project funded by CIFSRF attended an intervention nutrition education and demonstration session just prior to the midline data collection where mothers explained that although they understood the benefits of feeding their children pulses, they could not fully provide pulses as complementary food to their young children due to a shortage. At this time (late May and early June 2016), much of the population were affected by flooding that occurred due to an extended drought in the area. These climatic changes had prevented planting and/or reaping of pulses during the first harvest. The researchers decided to provide each of the mothers in the intervention group with two kg of quality haricot bean seed and two kg of fertilizer to plant during the June-July planting season. The women agreed to plant the seeds after a training session. Agriculture experts from Hawassa University's College of Agriculture (partner institution) trained 386 mothers for one day on techniques of planting, applying fertilizer, and weeding. The mothers in the control group were later provided with one kg of haricot bean seed at the end of endline data collection. The provision of a small amount of a new variety haricot bean seed was meant to enable smallholder female farmers to improve their wellbeing and that of their families.

Data analysis
Data were entered into SPSS version 20 software. Chi square and repeated measures Analysis of Variance (ANOVA) were used to investigate relationships between the pre-and post-intervention data on KAP of mothers, and growth and DDS of their children. ANOVA was used to compare means between the control and intervention groups, and when ANOVA was statistically significant, a post hoc test (Tukey HSD test) was used to determine the level of significance of values between and within groups. A values of p < 0.05 was considered as statistically significant.

Study Participants
A total of 772 mothers with children aged 6-15 months were recruited initially at the baseline. The total number of participants at baseline was 771 as one child was excluded due to not fulfilling the inclusion criteria. At the midline of data collection, the total number was 692 (354 in the intervention group and 338 in the control group), and at endline it was 621 (307 in the intervention group and 314 in the control group). A summary of the study participants' socio-demographic characteristics is presented in Table 1.

Knowledge, Attitude, and Practices of Mothers
Both the intervention and control group mothers had low scores on KAP at baseline. At midline, KAP improved in the intervention group (Fig. 2). After the 9-month nutrition education, mothers' mean knowledge (p = 0.001) and practices (p = 0.001) significantly improved, but the attitude score remained the same as the midline score. There was a (1.6%) from the intervention and three (1%) from the control group were able to recall the right proportion of cereal-pulse mix, which is 3/4th cereal and 1/4th pulse. At endline, 214 (69.7%) from the intervention and 37 (11.8%) from the control group reported that they soak and germinate pulse crops; only 23 (7.5%) from the intervention group could recall from memory all six steps of the household processing techniques, while none of the control group could. One hundred and forty-six (47.6%) from the intervention and 15 (4.8%) from the control group had learned the right proportion of cereal-pulse mix for preparing complementary food (Table 2). Haricot bean was the most commonly used pulse crop in the study area. Mothers who reported using pulses once or more than once per day in complementary food increased from 11.1% at baseline to 80.1% at endline in the intervention group and from 15.3% at baseline to 58.6% at endline in the control group. At baseline, there was no significant difference between the intervention and control groups in children's consumption of pulses (p = 0.47). At midline and endline, there was a significant difference in consumption of pulses between the control and intervention groups (p = 0.001). Figure 3 shows the frequency of pulse consumption by young children in both the intervention and control groups.
Mean dietary diversity at baseline was similar for the intervention children (2.1 ± 1.0) and controls (2.2 ± 0.8); at midline, values were 2.5 ± 0.8 and 2.2 ± 0.9, respectively and, at endline, 3.7 ± 1.4 and 3.2 ± 1.4, respectively. At baseline, only 23 (7.5%) from the intervention and 12 (3.8%) from the control group had consumed food from four or more food groups in the last 24 hours prior to data collection. At midline, 27 (8.8%) from the intervention and 26 (8.3%) from the control group had consumed food from four or more food groups in the same period. At endline, 158 (51.5%) from the intervention and 136 (43.3%) from the control had consumed food from four or more food groups.
There was a statistically significant difference between baseline and midline diet diversity (p = 0.001) and between midline and endline (p = 0.001) between and within groups, which indicated change overtime in both groups. Table 3 summarizes the food groups consumed by young children in the 24 hours prior to data collection at baseline, midline, and endline. Nutritional Status of Children Anthropometry measurements were measured in the study children at baseline, midline, and endline.
At baseline, there was no significant difference between the intervention and control groups in all anthropometry measurements and anthropometry indices. At endline, the mean age of male children was 18.8 ± 2.9 mo and female children was18.7 ± 2.9 mo. After intervention there was a significant difference (p < 0.05) in all anthropometric indices in the intervention group compared to the control group, as well as differences over time (Table 4). At baseline, low height and weight measurements were reflected in the high prevalence of stunting, wasting, and underweight. At midline and endline measurements, there were increases in the prevalence of stunting in both intervention and control groups; however, wasting and underweight improved only in the intervention group.   Table 4).

Women's Empowerment in Household Decision Making
All participating mothers (n = 386) in the intervention group reported that they had planted the haricot bean seed provided to them after the midline data collection. The seeds were later harvested following the endline data collection. Several visits to the field were carried out by the agriculture agents and the project team to a selected group of women; however, we did not collect information on how much they harvested, how much they kept for consumption, or how much they sold during endline data collection.

Discussion
The first two years of life are critical to reducing problems related to malnutrition [28]. The current study scaled-up this strategy by implementing a community-based nutrition education intervention entirely delivered through HEWs. The results of the study showed that mothers' KAP regarding pulseincorporated complementary food was low at baseline in both the intervention and control groups.
After four months of education (i.e., at midline), mothers in the intervention group improved KAP, which continued through the 9-month period. Almost all mothers in the intervention group had good knowledge about the benefits of pulses, household food processing techniques, and methods of preparation; they also started preparing complementary food using pulse crops. This current study findings are similar to other large intervention studies in other counties such as China [29,30] and Kenya [31], which showed improved mothers' knowledge about feeding practices when health service providers were used to provide nutrition education.
Improvements in the intervention group were seen in many measures. Frequency of pulse consumption significantly increased in the intervention group as most mothers started using pulses as a complementary food more than once per day. Frequency of pulse consumption increased in the intervention group after midline. Although, we lacked data on how much pulse crop the mothers' harvested, the provision of seed and fertilizer may have motivated those in the intervention group to prepare pulses for consumption more frequently. Furthermore, there was a significant difference in mean dietary diversity between the intervention and control groups. At the end of the intervention, consumption of pulses and nuts group improved significantly in the intervention group. Although the mean diet diversity in both groups improved at the midline and endline, the intervention group had a slightly higher mean diet diversity score than the control group. However, at endline, both groups were preparing foods from fewer food groups per day than recommended (i.e., less than four) [22].
Meal frequency in young children was significantly higher in the intervention group at both midline and endline. This study results were similar to those of a Chinese study, which was designed to improve the feeding practices of young children and found improved diet diversity as well as meal frequency in the intervention group [30].
Stunting increased with age in both groups, but by endline, less children were stunted in the intervention group than in the control group, which could reflect the positive impact of the intervention. The study findings were consistent with those of similar studies in Peru and China. A Peruvian study found a significant difference in stunting between the intervention and control groups and a reduced rate of stunting in the intervention group at the end of the study [32]. A Chinese study found a marginal significant difference in stunting between treatment and comparison groups [29].
Other similar studies have also observed a decreased rate of stunting and improvement in linear growth at the end of intervention, although these studies found no statistically significant difference between the treatment and comparison groups [33][34][35][36]. However, other studies have found neither improvement nor significant differences in stunting between the treatment and comparison group [15,31]. The range of the nutrition education period in most studies ranged from six to 18 months, a short time to find a significant change in stunting. In the current study, the prevalence of stunting increased with age, consistent with previous studies [33][34][35][36]. This increase in stunting with age could occur because of factors such as infectious disease, poor maternal malnutrition during pregnancy, poor hygiene, and poverty [31], all of which limit the impact of an intervention over a relatively short period. In the same way, in the current study, underweight also increased with age in both intervention and control groups. However, the prevalence of wasting decreased over time in the intervention group, whereas the number of children in the control group who were wasted increased at the endline.
In our study, we found household processing practices such as germination to be difficult tasks for mothers to adopt. The number of mothers who were using soaked and germinated pulse crops for complementary food was low. Only 43% and 69.7% of mothers in the intervention group reported soaking and germination pulses at midline and endline, respectively. However, the results showed that more mothers performed household processing techniques in the intervention group than in the control group. The number of mothers who adopted practices for soaking and germination of pulses in this study was higher than that in a similar study in Malawi, where only 25% of participants adopted the practices from the message [37]. This difference could be due to the length of intervention, which was shorter than this current intervention. In general, the effect of nutrition education on mothers' knowledge and practice was high at both the midline and endline of this study, but, attitude did not change after the midline, possibly indicating that an intervention of approximately five months could be sufficient to change mothers' attitude.
The strength of this study was the involvement of trained local HEWs who can speak the local language in delivering the nutrition messages. The intervention contributed to women's empowerment by using HEWs and training mothers in their own communities. A peer mentoring approach can have positive impacts on the knowledge, confidence, and attitudes of participants [38].
We have described the effects on HEWs elsewhere [39]. In addition, multiple educational theories, namely Theory of Planned Behavior (TPB) and Health Belief Model (HBM) were used in designing the messages. TPB helped to identify factors that may influence pulse consumption in feeding practices through a combination of attitudes towards consumption of pulses, household processing techniques, cultural influences, and behavioral control that results in the formation of an intention [18]. HBM helped in addressing the problem behaviour, in this case the risk of inappropriate feeding practice and low consumption of pulses leading to undernutrition [17]. The limitations of the study included the potential for information contamination between intervention and control sites. The distribution of seed after midline was an unexpected addition to the study; however, harvesting of these planted seeds had not occurred before endline, and thus this additional variable did not impact the results at nine months.

Conclusions
This study found that nutrition education delivered through HEWs was successful in improving young children's consumption of pulses and their nutritional status. The study showed that training local HEWs is an effective way of promoting locally available nutritious foods and improving the health of local communities, particularly in low-income countries. Specifically, we showed soaking and germination and to incorporating germinated pulse product into complementary food were skills that needed to be effectively taught. The HEW's network was important to bring changes in maternal KAP.
It is necessary to strength the training of HEWs on germination particularly as the skills were not easily adopted in the communities. It is also showed that scaled-up the messages using established health education networks is possible at the national level.