Malawi Medical Journal; 26 (4): 115-118 December 2014 Nutrition Education 115

The Effectiveness of Community-Based Nutrition

Education on the Nutrition Status of Under-five
Children in Developing Countries. A Systematic
Review
J Majamanda1*, D Maureen1,
children in developing countries is poor feeding practices such
as: introducing complimentary foods at an early or late stage,
T M Munkhondia2 and J Carrier3 restriction in food selection and giving children poor quality
1. Kamuzu College of Nursing, University of Malawi, Blantyre Campus, and insufficient amounts of complimentary foods.6,7,8,9 It is
P.O Box 415, Blantyre argued that poor feeding practices are associated with care-
2. Kamuzu College of Nursing, University of Malawi, Lilongwe Campus, givers poor knowledge, lack of information and their being
P/Bag 1, Lilongwe restricted by traditional beliefs10. Poverty is another major
3. Cardiff University, School of Nursing and Midwifery Studies, MSc
RGN PGCE Dip
cause and affects food choices1 With poverty, caregivers
tend to give children the food that is available regardless of
*Corresponding author, email: [email protected] its nutrition value11 Shortage of health-care providers, HIV
and AIDS and few health care facilities are some of the
Abstract contributing factors to malnutrition. In developing countries
there is critical shortage of health-care providers12.This has
Aim
been made worse by the accelerating labour migration which
This systematic review aimed at examining the best available evidence on
the effectiveness of community-based nutrition education in improving is causing loss of nurses and doctors from countries that
the nutrition status of under five children in developing countries. can least afford the brain drain13. There is also an increase in
disease burden due to HIV and AIDS and as a result more of
Methods
these health-care workers are based in the health care facility
A systematic search of the literature was conducted utilising the following
data bases: Cumulative Index to Nursing and Allied Health Literature
with few in the community. Consequently, primary care
(CINAHL), EMBASE, Medline, and Web of Knowledge. 9 studies were activities are not given a priority. There are a few health care
identified for the critical appraisal process. The Joanna Briggs Institute facilities which are located very far from people and as such
(JBI) critical appraisal check-list for experimental studies was utilised most people go to the hospital when they perceive an illness
and two reviewers conducted the appraisal process independently. 7 to be serious. As a result, health workers are mostly busy
studies were included for this review and data was extracted using the
JBI data extraction form for experimental studies. The extracted data was
attending to serious cases and do not give much attention
heterogeneous as such narrative synthesis was conducted. to preventive services such as health education. These
factors provide a threat to the attainment of health-related
Results
millennium development goals number 4 and 6, which aim to
The nutritional status of children in all studies improved and this was reduce child mortality and combat HIV/ AIDS, malaria and
evidenced by increases in weight, height, mid upper arm circumference
and reduced morbidity. Key messages about education were age at other communicable diseases respectively3. It is against this
introduction of complementary foods, nutrition value on different types background that numerous strategies have been put in place to
of feeds found locally and frequency of feeding the children. However, reduce the prevalence rate of malnutrition in children. These
there were varied results regarding the effects of the intervention on strategies are: provision of supplementary feeding, fortified
the nutrition status of children. This was attributed by differences in foods, immunisations and nutrition education1,14. To combat
implementers’ characteristics, different intervention strategy and intensity,
difference in age of the children at enrolment, pre-existing children’s malnutrition it has been recommended by many researchers
growth and nutritional status and follow-up periods. In addition to home that nutrition intervention should be accessible, sustainable,
visiting, conducting group meetings of care givers and community leaders, culturally sensitive and integrated with local resources7,15,16.
providing education twice a week and use of cooking demonstrations have One such intervention is the training of some community
shown that they produce highly significant findings. members to provide nutrition education to care-givers
Conclusion in their villages to prevent and improve childhood under-
The evidence from the identified studies suggests that community- based nutrition. This systematic review will therefore evaluate the
nutrition education improves the nutrition status of under-five children in best available evidence on the effectiveness of community-
developing countries. based nutrition education in improving the nutrition status
Background of under-five children in developing countries.
The prevalence of childhood malnutrition remains high in Methods
the developing world1. Malnutrition rate is high between A comprehensive and systematic search of CINAHL,
the ages of 6 to 24 months because breast milk alone is not EMBASE, MEDLINE, PubMed and Web of Knowledge
enough to meet the nutritional needs of the child and other was undertaken utilising synonyms of the following key
foods are introduced2. World Health Organisation (WHO)3 terms: Children, Community- based nutrition education and
defines complimentary feeding as the introduction of other Nutrition Status. Search strings were created by combining
foods and/ or energy containing liquids to young children the Boolean operators OR and AND. The search included
in addition to breast milk. While some studies indicate that studies with the following qualities: randomised controlled
complementary feeding can be introduced at 4 months4,5 trials, quasi experimental studies, primary research from
WHO6, recommends that children should be introduced to peer- reviewed journals, studies that used nutrition education
complementary foods at 6 months. The food that is given or counselling as interventions The interventions were
should be safe, adequate and appropriate to prevent growth delivered within the community or at home to groups or
faltering in under-five children thereby reducing childhood individual care takers by health-care providers and trained
deaths.4One of the major causes of malnutrition in young community members and/ or peer counsellors. Before

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Malawi Medical Journal; 26 (4): 115-118 December 2014 Nutrition Education 116
the implementation of the intervention, the implementers Table 2: Results
should have received training on nutrition content The
studies should have been written in the English language,
conducted in developing countries and whose outcomes
were increase in weight and height. The review excluded
studies that evaluated the effectiveness of provision of
supplementary or complementary feeding; those that
combined the interventions of education and provision
of supplementary feeding, systematic reviews, studies that
looked at education provided at a health facility and those
that looked at education provided to children at school.
The search identified 5,074 articles for review. After reading
the topic and abstract, 38 articles were identified. Full text
articles assessed for eligibility were 25. After removing
duplicates and systematic reviews, 9 studies were identified
and appraised by two reviewers for methodological quality
using the standardised critical appraisal instrument for
Experimental Studies from the Joanna Briggs Institute. This
process resulted in 7 studies for inclusion in this review
(figure 1).
These findings show that community-based nutrition
education is effective in improving the nutrition status of
Fig 1: Literature search and study identification
under-five children in developing countries. This is evidenced
by the increase in weight18,21, length,8 weight and height,10,20
weight, height and Mid Upper Arm Circumference19 weight
and reduced morbidity.17
Discussion
Results from this review suggest that nutrition education
provided to care-givers in their homes or community
improves the nutrition status of under-five children in
developing countries. To produce highly significant results,
findings from this review suggest conducting group
meetings of care givers and community leaders, providing
education at frequent intervals for example twice a week
and use of cooking demonstrations in addition to home
visiting. Providing nutrition training to implementers prior
to implementation of the study helped them to demonstrate
higher levels of nutrition knowledge and counselling skills
which they previously lacked22. This helped them to provide
relevant nutritional education to care givers hence significant
results were produced. However, this review has found
varied results regarding the effects of the intervention on
the nutrition status of children. The possible reasons for the
difference are: different intervention strategy and intensity,
Table 1: Characteristics of included studies difference in age of the children at enrolment, pre-existing
children’s growth and nutritional status. This was also
previously reported in7 where they looked at effectiveness
of educational interventions for improving complementary
feeding practices. The difference with this review is the
setting in which the implementation was conducted. In7 the
interventions were delivered in various settings including
the hospital while this review concentrated on educational
interventions delivered in the community or home. In
addition, implementers for studies in this systematic review
had different characteristics. In 8 studies health-care providers
and nutrition workers implemented the intervention. In
17 studies the implementers were graduate-level health
assistants,18 used community health workers 21 used mentor
mothers and 10,19,20 had trained community members
and/ or peer counsellors. Health care providers, nutrition
workers, graduate-level health assistants and community
health workers may have had good understanding of
nutrition as a subject and experience in community teaching

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Malawi Medical Journal; 26 (4): 115-118 December 2014 Nutrition Education 117
compared to community members and peer counsellors. Conflicts of interest
These implementers were able to disseminate information There are no financial and non-financial conflicts of interest
to the intervention group in a simple way hence results of in this review
their studies were highly significant.Comparing children of
different nutritional status would not bring the same effect Authors’ Contributions
of the intervention because malnourished children usually Maureen D. Juma Majamanda developed a protocol for this
present with other medical conditions due to reduced review, conducted the search strategy, appraisal of studies,
immunity and as such, their appetite is reduced and they data extraction and data synthesis under the supervision of
would not eat well compared to normal children. Even when Judith Carrier. Tiwonge Mbeya Munkhondia conducted the
the malnourished child eats well, the nutrients will be used appraisal of studies. All contributed to the editing of this
to treat or rehabilitate the condition first and then later for manuscript.
catch up growth23. Having children of different nutritional
status in the same study meant that the nutrition education
Acknowledgements
was the same yet they had different nutritional needs. This I would like to thank Judith Carrier for her guidance and
might mean that the care-givers followed the advice that they support. This work was supported by funding from the
were given, only that it did not suit their children’s needs. In Government of Malawi through University of Malawi. The
this case the nutrition status of malnourished children would funding was granted to the first author as part of Masters
not improve at the same rate as that of normal children. studies.
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