{"paper_id":"08ec3cfb-e590-48bc-9b26-6e7bb8fe4b72","body_text":"Full Title: \nImpact assessment of social behavioral change activities on infant \nand young child feeding (IYCF) of the nutrition program in the host \ncommunity \nTaslima Arzu1¶, S.M. Symon Bappy2, Md. Alamgir Hossain3¶, Monowarul Islam4, \n, Vulon Prosad5, Suparna Das Toma6, Md. Ariful Kabir Sujan7¶ \n \n \n1World Vision Bangladesh, Cox’s Bazar, Bangladesh \n2World Vision Bangladesh, Cox’s Bazar, Bangladesh \n3World Vision Bangladesh, Cox’s Bazar, Bangladesh \n4World Vision Bangladesh, Cox’s Bazar, Bangladesh \n5Gonoshasthaya Kendra, Cox’s Bazar, Bangladesh \n6Nutrition Sector, Cox’s Bazar, Bangladesh \n7Gonoshasthaya Kendra, Cox’s Bazar, Bangladesh \n \n \nCorresponding Author:  \nEmail: tanu04anft@gmail.com,  \n \n \nAbstract  \nAims: The purposes of the impact assessment for the Social Behavioral Change (SBC) activities in \nthe nutrition program in the host community were: to measure the impact of the Social Behavioral \nChange (SBC) activities to ensure the optimum infant and young child feeding (IYCF), especially on \nthe pregnant and caregiver of under 2 years children on IYCF activities and to provide \nrecommendations based on an overall assessment. \nStudy design: The study was designed to review the secondary nutrition program performance \ndata and conduct a cross-sectional study using both quantitative and qualitative data collection to gain \ndeep insight into the impact of the SBC activities on changing the behavior of the target population. \nPlace and Duration of Study: Data was collected in the host community, where the coastal & \nthe poorest people from the host community were staying and getting nutrition support in Moheshkhali \nand Pekua of Coxs Bazar district of Bangladesh.  \nMethodology: A household survey was conducted to collect quantitative data from the project \nbeneficiaries. This survey was tailored to gather relevant indicators and assess the effectiveness of \nthe interventions. Quantitative data were collected from the beneficiaries through household surveys. \nWe included 224 pregnant and lactating women (PLW) and 227 caregivers of 0-59-month-old children \n(4 males and 447 females). Qualitative data were obtained through Focus Group Discussions (FGDs-\n8; 8-10 females) and Key Informant Interviews (KIIs-8; MtMSG members, nutrition and health staff, \nand participants from cooking demonstrations). \nResults: A complete package of SBC approach to breaking the social stigma and barrier targeting \nthe audience through different methods; for example, to improve the Infants and Young Child Feeding \n(IYCF) indicators by providing IYCF messages through health and nutrition education, group \nmessaging at IYCF corner, Community sensitization, meetings and workshops, mother-to-mother \nsupport groups, and IYCF counseling from health facilities. Complementary feeding cooking \ndemonstration for hands-on learning can change the negative behavior of the targeted audience in a \npositive direction. In this study, we found that 61.2% of mothers changed one of the negative \nbehaviors related to IYCF in a positive direction. \nAll mothers knew the importance of exclusive breastfeeding, and 73.0% of mothers practiced it \nproperly, which is higher than the current exclusive breastfeeding rate of 62.1% (IYCF Survey 2022 \nby ACF) (11). 52.8% of mothers ensured the minimum dietary diversity, and 35.8% ensured the \nMinimum Acceptable Diet (MAD) of complementary feeding for children 6-23 months, which came \nfrom the complete SBC approach to IYCF practices. \n . CC-BY 4.0 International licenseIt is made available under a \n is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity.(which was not certified by peer review)preprint \nThe copyright holder for thisthis version posted November 19, 2025. ; https://doi.org/10.1101/2025.11.17.25340405doi: medRxiv preprint \nNOTE: This preprint reports new research that has not been certified by peer review and should not be used to guide clinical practice.\n\nConclusion: This comprehensive study of secondary data review and qualitative findings with \nvalidation through the quantitative survey finds that a comprehensive nutrition activity engaging the \ntarget population in the SBC activities changes the social stigma and barrier. \nAll mothers who attended the study expressed proper knowledge of IYCF and also emphasized their \nphysical and mental health to ensure proper IYCF practices for children 0-23 months, such as \nexclusive breastfeeding for the first six months, starting complementary feeding after six months, and \nensuring the minimum food diversity to ensure proper nutrition of the young children. This group of \nmothers can work and support other mothers in the best practices of IYCF and break the social \nstigma and barriers of IYCF practices. \n \n \nKeywords: Behavioral Change, Breastfeeding, Malnutrition, Host community, Infant and Young Child \nFeeding  \n \n1. Introduction \nAs the community-based management of acute Malnutrition (CMAM) nutrition program has been \nrunning since 2014 in the host community of Moheshkhali and Pekua of Cox’s Bazar district, the \nmalnutrition situation remains critical (Global Acute Malnutrition, GAM is 14.7% in Moheshkhali and \n11.7% in Pekua at the year of 2021(1, 2), especially for children 6-23 months of 20.0%. Early \nchildhood malnutrition leads to chronic malnutrition, such as stunting among older children (Stunting \namong children 6-23 months; 27.5% & 24-59 months; 34.4% (2) in Moheshkhali and among children \n6-23 months; 27.5% & 24-59 months; 34.4% in Pekua (1). We are focusing here on the SBC \napproach to improve malnutrition and negative behaviour, which are affecting children under 2 years \nwith a high Global Acute Malnutrition (GAM) rate in a positive direction, so that the malnutrition \nsituation can improve and the sustainability of the nutrition messages.  \nMalnutrition is a persistent health problem among children in Bangladesh, especially children under 2 \nyears, due to the lack of proper weaning foods, both diverse and balanced (3,4).  The optimal infant \nand young child feeding practices during the first 2 years of life are of paramount importance as this \nperiod is the “critical window” for the promotion of health, good growth, and behavioral and cognitive \ndevelopment. Optimal infant and young child feeding practices include initiation of breastfeeding \nwithin 1 hour of birth, exclusive breastfeeding for the first 6 months, and continuation of breastfeeding \nfor 2 years or more, along with nutritionally adequate, safe, age-appropriate, responsive \ncomplementary feeding starting at 6 months. [5]. It was estimated that about one-fifth of overall under-\nfive mortality can be averted if 90% of infants are covered with an inclusive package of interventions \nto promote, protect, and support the optimal infant and young child feeding (IYCF) practices. [6]. A \nlarge proportion of children become vulnerable to stunting, poor cognitive development, and \nsignificantly increased risk of infectious diseases, such as diarrhea and acute respiratory infection, \ndue to poor complementary feeding practices. [7]. Epidemiological evidence of a causal association \nbetween early initiation of breastfeeding and reduced infection-specific neonatal mortality has also \nbeen documented. [8]  \n \nThe findings from the 2022 IYCF survey among the host communities offer valuable insights, \nhighlighting both encouraging trends and areas of concern. While 62.1% of children under six months \nwere reported to be exclusively breastfed, the continued practice of giving prelacteal feeds—often \ndriven by cultural and religious beliefs—remains an issue (9). Among children aged 6–23 months, \nonly 31.3% met the Minimum Dietary Diversity (MDD) and 26.0% met the Minimum Acceptable Diet \n(MAD) criteria, which is particularly alarming (9). The positive aspect is that the caregiver engagement \nin nutrition education is notably high, with 96.0% reporting active participation in sessions over the \npast 23 months, despite generally low education levels among caregivers of children aged 0–23 \nmonths. Only 4.0% reported being unable to attend these sessions during the same period. (10) \nThe optimum IYCF practices have a great impact on the physical and mental development of the child \n(11). Breastfeeding strengthens emotional security and affection, creating a strong bond between the \n . CC-BY 4.0 International licenseIt is made available under a \n is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity.(which was not certified by peer review)preprint \nThe copyright holder for thisthis version posted November 19, 2025. ; https://doi.org/10.1101/2025.11.17.25340405doi: medRxiv preprint \n\nmother and the child, which in turn promotes the psychosocial development of a child. To ensure the \ngood nutrition status of the infant as well as the mother, maternal nutrition plays a vital role. \nBreastfeeding is nature’s way of nurturing the child. It provides learning and development \nopportunities for the infant. Breast milk also leads to increased intelligence quotients and better visual \nacuity due to the presence of special fatty acids in it. (12) \nThe IYCF practices are strongly influenced by what people recognize, think, and believe, and who \ntraditionally encourage mothers to breastfeed by giving information on the benefits of breastfeeding \nfor the infant and the mother herself. Women's behaviour can be easily positively modified through \nreligious teachings. Breastfeeding may be affected by religious ideologies using the doctrine in \nreligious texts, affected by social circumstances, and economic factors. Effective communication for \nbehavioural change is necessary for ensuring optimal infant feeding (11,13,14). Counselling the \nmothers by reinforcing the cultural and religious practices supporting breastfeeding can help \nenormously. The use of local religious teachings can bring positive changes in the implementation of \nhealth & nutrition programs (11,12). Community-based IYCF counselling and support can play an \nimportant role in improving these practices: it can ensure access to these services in the poorest and \nthe most vulnerable communities with limited access to health care and therefore become an \nimportant strategy for programming with an equity focus. (11,12). Public nutrition education that \npromotes infant and young child feeding as defined by WHO, considering social-cultural factors, is \nneeded and recommended (11,15). \nThe social behavioural change (SBC) communication activities include community screening of \nchildren and pregnant and lactating women (PLW) with the dissemination of IYCF messaging at the \nhousehold level, courtyard sessions with complementary cooking demonstration, Growth monitoring, \nand promotion (GMP) of the children under five years. The optimum maternal, infant, and young child \nfeeding (IYCF) and care practices through one-to-one IYCF need-based messaging, group \nmessaging, Mother to Mother Support Groups (MtMSG), Father Support Group, and community \nsensitization through World Breastfeeding Week celebration, Nutrition Action Week, etc.  \nThe purposes of the impact assessment for the SBC activities in the nutrition program in the host \ncommunity were: to measure the impact of the Social Behavioural Change (SBC) activities to ensure \nthe optimum infant and young child feeding (IYCF), especially on the pregnant and caregiver of under \n2 years’ children on IYCF activities and to provide recommendations based on an overall assessment \nto improve the IYCF conditions for better outcome of the nutrition program. \n \n2. Method And Materials  \nThe tools used both qualitative and quantitative methods to ensure a thorough assessment by cross-\nchecking data. \n \n2.1. Sampling Frame:\n Households and individual beneficiaries from the Moheshkhali and Pekua \nwere the focus of our data collection efforts. \n2.2. Quantitative Data: A household survey was conducted to collect quantitative data from the \nproject beneficiaries. This survey was tailored to gather relevant indicators and assess the \neffectiveness of the interventions. Quantitative data were collected from the beneficiaries by a \nhousehold survey. The sample size calculator Raosoft (where confidence level is 95%, response \ndistribution is 50%, and margin of error is 6.5%) was used to calculate the sample size for the \nHost Community. \n \nWhere,   \n• Initial = minimum required initial sample size (before adjusting for finite population \ncorrection).  \n . CC-BY 4.0 International licenseIt is made available under a \n is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity.(which was not certified by peer review)preprint \nThe copyright holder for thisthis version posted November 19, 2025. ; https://doi.org/10.1101/2025.11.17.25340405doi: medRxiv preprint \n\n• p = an estimate of the true (but unknown) population (project participant) proportion at \nbaseline=50% (0.50). \n• Z = critical value from a normal probability di stribution (Z-score corresponding to the 95% \nconfidence level) [Z = 1.96 at 95% confidence level]. \n• MOE = margin of error (acceptable percentage error) = 0.065 (6.5%). \n• d = Design effect, a two-stage PPS cluster sampling procedure is proposed, and in that \ncase, the design effect might be close to two [d = 2]. \n• NF = non-response factor [1.10] (assumes a 10% non-response rate). \n \nTable 1: Population type and quantitative sample for the assessment \nPopulation type Target Sample \nPregnant and Breastfeeding women (PBW) \n(Screening, counseling, MtMSG, messaging, etc.) \n15,221 224 \nChild (0-59 months), but the respondent will be the mother and \ncaregiver.  (Screening, GMP, WBW, NAW) \n71,030 227 \nGrand Total 451 \n \n2.3. Qualitative Data: Qualitative data were obtained through Focus Group Discussions (FGDs) and \nKey Informant Interviews (KIIs). \nTable 2: Number of FGD and KII conducted \nWhat \nHost   \nTotal Participant type/Activity Quantity \n \nKII \nGraduated MCG/MtMSG (graduated)  3  \n8 Nutrition staff 2 \nGO/NGO relevant representative  3 \nFGD \nCooking session of MtMSG, and local \nleader/Imam meeting. 4  \n8 \nCaregivers of the under-five children  4 \n \n2.4. Data Collection and Capacity Building \nBefore the start of data collection for the host community, the nutrition staff and the Monitoring, \nEvaluation, Accountability and Learning (MEAL) team served as data collectors. The MEAL team \nconducted orientation sessions for both groups on the proper use of all tools, with support from the \nDeputy Program Manager and Program Manager if needed. \nDuring the orientation, the program team provided the venue and snacks for the data collection team. \nThe team conducted a pilot test of the finalized tools to ensure they functioned as expected and \ncaptured the required data. All team members are proficient in both English and the local language, \nand have experience using the KoBo Toolbox or similar ODK platforms. Data collection began once \nthe team had demonstrated full confidence and competence with the tools and processes. \n2.5. Ensuring Reliability and Validity  \nTo maintain high data quality throughout the process, it was ensured that all the data collection tools \nwere in English and understandable to the team, and all enumerators were provided with thorough \ntraining before data collection began, ensuring they were proficient in communicating in the local \nlanguage. The data collection tools were piloted and refined based on the feedback from the piloting \nphase. Continuous supervision was maintained throughout the data collection process to ensure \naccuracy and adherence to protocol.  Regular reviews of the collected data were conducted, and \ncorrective actions were taken as necessary.  Data validation checks were performed to minimize \nerrors; the datasheet and the data were error-free. Unnecessary or irrelevant questions were avoided \nin the tools, as this would increase data collection time for both qualitative and quantitative \nassessments. \n \n \n . CC-BY 4.0 International licenseIt is made available under a \n is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity.(which was not certified by peer review)preprint \nThe copyright holder for thisthis version posted November 19, 2025. ; https://doi.org/10.1101/2025.11.17.25340405doi: medRxiv preprint \n\n2.6. Limitations \nDuring the rainy season, heavy rainfall makes it uncomfortable for beneficiaries to participate in \ninterviews, as they could get soaked or feel uneasy. To solve this, interviewers arranged safe and dry \nplaces where people can comfortably answer questions. Some women also felt shy or hesitant to \nshare information due to cultural reasons. To overcome this, we chose interviewers (provided female \nCommunity Nutrition Volunteers (CNV) or Staff) who were sensitive to these issues and used \nrespectful, culturally appropriate language in the questions. Additionally, political tensions or sudden \nweather changes, like storms and internet disruptions, could interrupt data collection. The team kept \ntrack of security updates and adjusted plans to ensure safety.  \n3. Result  \n3.1. Nutrition program coverage for the SBC activities \nTable 3: Program performance assessment by evaluating the target vs achievement \nIndicators Target Achievement % \nCommunity MUAC Screening of U5 73,934 71,030 96% \nCommunity MUAC Screening of PLW 19,758 15,221 77% \nGrowth Monitoring and Promotion (GMP) 81,163 71140 88% \nIYCF group Messaging 44,378 39,841 90% \nCourtyard session at the cluster level 5437 6192 114% \nMother to Mother Support Group (MtMSG) 59 59 100% \nVitamin-A Campaign 73934 93629 127% \nDeworming Campaign 49314 78,346 159% \nIFA Supplementation for PBW with MIYCN messaging 4057 3493 86% \n3.2. Survey Results & Discussion \nFigure 1: Demographic information of the respondents (N=451) \n \n \n \nTable 4: Results from the quantitative assessment \nIndicators Category N Response % \nDoes CNV measure your child at the HH level  Yes 451 416 92.2% \nHow many times did CNV visit HH for screening in the \nlast quarter? \n1 time \n416 \n13 3.1% \n2 time 17 4.1% \n3 time 386 92.8% \nMeasured for GMP & Provide Counselling  Yes 276 265 96.0% \nDo you receive GMP key messages?  Yes 276 261 94.6% \nDid you receive the IYCF key message through MtMSG?  Yes 289 262 90.7% \nHow many IYCF key messages are there?  1-Message \n262 \n4 1.5% \n2- Messages 11 4.2% \n3-Messages 68 26.0% \n4-Messages 179 68.3% \nDid you receive one-to-one counseling?  Yes 289 182 63.0% \nEarly Initiation of breastfeeding within 1 hour after delivery (aged 0-23 months) 308 301 97.7% \nExclusively breastfeeding (EBF) among children 0 -5 months of age 115 84 73.0% \n0\n100\n200\n300\n400\n500\nPW B W Mother (<2 \nchi ld)\nMother (2- 5 \nchil d)\nM al e Fem al e 0-5 M ont hs \n(BW  + \nchi ldren)\n6- 23  M ont hs 24- 59 Months\nRespondent type (N=451) Sex r espondent Chi ld Age ( N=340)\n107\n68\n113\n163\n4\n447\n68\n114\n162\n23.7% 15.1% 25.1% 36.1% 0.9% 99.1% 19.8% 33.1% 47.1%\nDemographic information of the respondents (N=451)\nFr e que nc y %\n . CC-BY 4.0 International licenseIt is made available under a \n is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity.(which was not certified by peer review)preprint \nThe copyright holder for thisthis version posted November 19, 2025. ; https://doi.org/10.1101/2025.11.17.25340405doi: medRxiv preprint \n\nChildren (aged 6–23 months) have Minimum Dietary Diversity (MDD) (at least 4 food \ngroups) 193 102 52.8% \nMinimum Acceptable Diet  (MAD)for children 6-23 months 193 69 35.8% \nIn the past six months, have you changed any of your nutritional habits in a positive \ndirection?  451 276 61.2% \n \n3.3. Nutritional status of the children from the Survey \nFigure 2: Nutritional status of the children whose caregivers or mothers attended SBC activities (Wasting) \n \n \nGAM: Global Acute Malnutrition, SAM: Severe Acute Malnutrition, MAM: Moderate Acute Malnutrition, SENS: Standardized Extended N utrition \nSurvey \n3.4. The result from the qualitative assessment \n3.4.1.1. Insights of KII (health and nutrition Staff) \n• Areas with high malnutrition and vulnerability were chosen to help those who need it most by \nregular analysis of program data, program coverage & performance. \n• Field visits and reports were used to check the work and ensure it was done well. \n• Challenges like hard-to-reach areas and limited access for marginalized groups make it harder to \ncontinue the work long-term. \n• Children under 2 years and pregnant or breastfeeding women were prioritized to get help first and \nensure their visit to the IYCF corner for initial assessment of breastfeeding problems, and provide \nservices according to the assessment findings. \n• Communities were involved through activities like workshops and sensitization meetings to make \nthem feel part of the project. \n• Pregnant and lactating women are trained on IYCF, childcare, and feeding for the sustainability of \nthe program activities through group messaging, counseling, and Mother to Mother Support group \nactivities. \n3.4.1.2. Insights of KII and FGD \n• Model mothers share key messages on breastfeeding, nutrition, and hygiene, improving child \nhealth, and empowering mothers in the community. \n• A supplementary cooking session on complementary feeding (CF) with six female participants (one \ncaregiver and five other women) improved understanding of breastfeeding, complementary foods, \nand hygiene practices, promoting better family health. \n• A complementary cooking session with ten female participants (one PBW, nine caregivers) \nemphasized nutrient-rich feeding alongside breastfeeding, enhancing child nutrition and hygiene. \n0. 00 %\n2. 00 %\n4. 00 %\n6. 00 %\n8. 00 %\n10 . 0 0%\n12 . 0 0%\n14 . 0 0%\n16 . 0 0%\nGA M MAM SAM\nNutritional status of the children \nI m pa c t  S ur v e y  SM A RT  S ur v e y  2 02 1 at  P e k ua S M A R T Su r v e y  20 21  M ohe s hk ha li\n . CC-BY 4.0 International licenseIt is made available under a \n is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity.(which was not certified by peer review)preprint \nThe copyright holder for thisthis version posted November 19, 2025. ; https://doi.org/10.1101/2025.11.17.25340405doi: medRxiv preprint \n\n• A courtyard session with 14 participants (one male, 13 females: one PBW, five caregivers, eight \nother women) improved knowledge of child nutrition and hygiene, fostering healthier practices and \nactive community sharing. \n• 100% of lead mothers understand that the mother aims to enhance physical & mental health and \nwell-being, and they also emphasize breastfeeding. \n• 100% of participants from MtMSG mothers (Out of 11) knew that only the first breast milk for the \nfirst 6 months of the child. \n• 100% of mothers' positive response after 6 months of starting to feed complementary food. \n \n4. Discussion  \nThis comprehensive study of secondary data review and qualitative findings, with validation through the \nquantitative survey, finds that a comprehensive nutrition activity and engaging the target population in nutrition \nprogram activities change the social stigma and barriers & improve the nutritional status of the children and \nPregnant and Breastfeeding women. A complete package of Social Behavioral Change (SBC) activities \ntargeting the most vulnerable groups to break the malnutrition life-cycle through different methods; for \nexample, to improve the nutritional status through improving the Infants and Young Child Feeding (IYCF) \nindicators by providing IYCF messages through health and nutrition education, group messaging at IYCF \nCommunity Clinic, Community sensitization, meetings and workshops, mother-to-mother support groups, \nIYCF counseling from health facilities, improving immunity through micronutrient (IFA, Vitamin-A, and \nDeworming, etc.) supplementation with IYCF messaging. The quantitative survey showed that the nutritional \nstatus (wasting) of the children improved from 11.7% in Pekua and 14.7% in Moheshkhali (1, 2) to 10.9% in \nthe host community of Moheshkhali and Pekua. \nThe IYCF practices are strongly influenced by what people know, think, and believe, and are also affected by \nsocial circumstances and economic factors. Effective communication for behavioral change is necessary for \nensuring optimal infant and young child feeding. Awareness regarding IYCF practices and their benefits in \nMaternal and Child Health (MCH). (4,11,12,13) \nAll mothers practiced the Infants and Young Child Feeding (IYCF) indicators; the importance of exclusive \nbreastfeeding, and 73.1% of the mothers from the host community practice exclusive breastfeeding (62.1% \n2022) (9).  35.8% of mothers from the host community ensured the Minimum Acceptable Diet (MAD), with \n52.8% having the Minimum Acceptable Diet (MDD) of complementary feeding for children 6-23 months, which \ncame from the complete SBC approach to IYCF practices. \nCooking demonstrations with proper messages on complementary feeding for children 6-23 months for \nhands-on learning can change the negative behavior of the targeted audience in a positive direction. In this \nstudy, we found that 61.1% of mothers from the host community changed one of the negative behaviors \nrelated to IYCF in a positive direction.  \nThe IYCF practices are strongly influenced by what people know, think, and believe, and are also affected by \nsocial circumstances and economic factors. Effective communication for behavioral change is necessary for \nensuring optimal infant and young child feeding. Awareness regarding IYCF practices and their benefits in \nMaternal and Child Health (MCH). (16,17,18, 19,20) \n5. Conclusion & Recommendations \n \nDespite these successes, challenges are not at an end: deep-rooted cultural and geographical isolation and \neconomic constraints create unequal access to services. Among the recommendations that have emerged \ntoward improving the impact and sustainability of the SBC approaches for outreach to marginalized or \nunderrepresented groups with effective, culturally sensitive strategies and promotion of awareness through \ndigital instruments. It is also critically important that male family members and local leaders be involved in \ncommunity-level SBC campaigns. \nRecommendations came from the impact assessment of SBC approaches: \n• Address barriers faced by marginalized groups through targeted outreach, culturally sensitive \nmaterials, and ensuring accessible session locations and timings. \n . CC-BY 4.0 International licenseIt is made available under a \n is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity.(which was not certified by peer review)preprint \nThe copyright holder for thisthis version posted November 19, 2025. ; https://doi.org/10.1101/2025.11.17.25340405doi: medRxiv preprint \n\n• Engage local leaders, model mothers, and community members in planning and implementing \nprograms to foster ownership and trust, ensuring sustained impact. \n• Increase the frequency of monitoring visits, conduct regular data analysis, and adapt interventions to \nalign with evolving community needs and feedback. \n• Utilize visual aids, hands-on demonstrations, and affordable, locally available food options to address \naffordability and improve message retention. \n• Conduct regular training sessions for nutrition staff and volunteers, focusing on technical skills and \nservice delivery. \n• Scale up awareness campaigns focusing on practical, low-cost IYCF practices, emphasizing \nexclusive breastfeeding, complementary feeding, and hygiene as critical components of child health. \n• Develop culturally appropriate messages to address barriers to breastfeeding and dietary diversity. \n• Engage male family members and community influencers to support women's participation in nutrition \nprograms. \n6. Acknowledgement \nOn behalf of the Research team, we would like to acknowledge all Caregivers of children under five, Pregnant \nand Lactating Women, and the religious leaders who have shared their opinions and experiences in this \nstudy. Their ideas and suggestions are invaluable in future programming aiming to reduce the impact of ration \ncuts on the nutritional status of children under five, pregnant and lactating women, and other vulnerable \ngroups. \n We acknowledge the support of other stakeholders, including Nutrition staff who conducted qualitative studies \nthrough focus group discussions (FGDs) and key informant interviews (KIIs) at the field level. \n \n7. Ethical Consideration \nTo protect the participants, especially children and pregnant or lactating women, the guiding principles for \ndata collection included voluntarism, confidentiality, and anonymity. Participation was strictly voluntary. In the \nbeginning, the purpose of the study was explained, and it was made certain that the information provided \nwould be kept confidential. They were free to withdraw or skip any question without any repercussions. \nDo No Harm:  The questions were constructed to do no harm and cause no discomfort to the respondents. \nSupport was given for sensitive issues, or further resources were provided where appropriate. \nIntegrity: Data reported fully and with accuracy. Full effort was made to double-check information and make \nsure information was presented correctly in its proper context. \nParticipant Feedback: Findings related to key issues were fed back to the community and participants to \nincorporate their views into the final report. \nChild Protection: In sessions involving children, a responsible adult was also present; children were never \nasked anything that could make them remember something personal and hurt them. Interviewers followed \nguidelines for child protection strictly because it is relevant to safety. \n8. Informed Consent  \nBefore the start of quantitative and qualitative data collection, the survey team will have a minute or two of \nintroduction and the purpose of the survey, and how long the survey will take for the respondents. The team \nwill also guarantee the respondent or the FGD group the confidentiality and privacy of the information that will \nbe collected during the survey. No personal and family information shall be revealed during reporting, and the \nrights and privacy of the respondents shall be respected. If she/he wishes not to respond to questions or \nwishes to drop the survey, both quantitative and qualitative. Therefore, the survey only proceeds upon getting \ninformed consent from the respondent and or the FGD group participants. \nThe participants were selected equitably, and their informed consent was sought to ensure that they \nparticipated in the study voluntarily. \n9. Ethical Approval  \nAs the ethical approval authority at the district level for health and nutrition is the Civil Surgeon, approval for \nthe survey was obtained from the respective authorities, including the Civil Surgeon (CS), Upazila Health and \nFamily Planning Officer (UH&FPO), and the Chairman of the respective Unions.  \n10. Supporting Information \n \nS1 Table 1: Population type and quantitative sample for the assessment (PDF) \n . CC-BY 4.0 International licenseIt is made available under a \n is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity.(which was not certified by peer review)preprint \nThe copyright holder for thisthis version posted November 19, 2025. ; https://doi.org/10.1101/2025.11.17.25340405doi: medRxiv preprint \n\nS2 Table 2: Number of FGD and KII conducted (PDF) \nS3 Table 3: Program performance assessment by evaluating the target vs achievement (PDF) \nS4 Figure 1: Demographic information of the respondents (PDF) \nS5 Table 4: Results from the quantitative assessment (PDF) \nS6 Figure 2: Nutritional status of the children whose caregivers or mothers attended SBC activities (Wasting) \n \n \n11. Author Contributions \nConceptualization: Taslima Arzu, Md, Ariful Kabir Sujan, S.M. Symon Bappy & Md. Alamgir Hossain. \nData curation: Taslima Arzu, Md. Ariful Kabir Sujan, Md. Alamgir Hossain, Monowarul Islam, Viulon Prosad, \nSuparna Das Toma \nFormal analysis: Taslima Arzu, Md. Ariful Kabir Sujan, Md. Alamgir Hossain, Monowarul Islam, Viulon Prosad \nMethodology: Taslima Arzu, Md. Ariful Kabir Sujan, Md. Alamgir Hossain \nSoftware: Md. Ariful Kabir Sujan, Monowarul Islam, S, M, Symon Bappy \nSupervision: Taslima Arzu, Md. Ariful Kabir Sujan, Md. Alamgir Hossain \nWriting – original draft: Taslima Arzu, Md. Ariful Kabir Sujan \nWriting – review & editing: Taslima Arzu, Md. Ariful Kabir Sujan, S.M. Symon Bappy, Md. Alamgir Hossain, \nMonowarul Islam, Suparna Das Toma, Vulon Prosad \n \n12. References \n1. Nutrition Sector. (2021, June). Follow-up integrated SMART nutrition survey in Pekua Upazila, Cox’s Bazar \nDistrict, Bangladesh . https://reliefweb.int/report/bangladesh/follow-integrated-smart-nutrition-survey-pekua-\nupazila-coxs-bazar-district-bangladesh-june-2021-final-survey-report  \n2. Nutrition Sector. (2021, July). Follow-up integrated SMART nutrition survey in Moheshkhali Upazila, Cox’s \nBazar District, Bangladesh . https://reliefweb.int/report/bangladesh/follow-integrated-smart-nutrition-survey-\nmoheshkhali-upazila-coxs-bazar-district-bangladesh-june-2021-final-survey-report  \n3. Taslima Arzu, Md. Ariful Kabir Sujan, Dr. Md. Sabir Hossain, \"Assessment of Infant and Young Child Feeding \nIndicators with Special Emphasis on Practices and Knowledge of Mothers in Rural Areas\", International \nJournal of Science and Research (IJSR), Volume 6 Issue 10, October 2017, pp. 888-891,  \nhttps://www.ijsr.net/getabstract.php?paperid=ART20176925, DOI: \nhttps://www.doi.org/10.21275/ART20176925    \n4. Arzu, T., Satter, M. A., Paul, D. K., Sujan, A. K., Jabin, S. A., Mitra, K., Islam, D., et al. (2024). Comparison \nbetween low-cost locally produced complementary foods with high-cost imported complementary foods \navailable in Bangladesh by Rat Bioassay. Internationa l Journal of Life Science Research Archive, 7(1), 019-\n027. 10.53771/ijlsra.2024.7.1.0058   \n5. World Health Organization. Infant and Young Child Feeding: Model Chapter for Textbooks for Medical \nStudents and Allied Health Professionals. France: World Health Organization, 2009 \n6.  Black RE, Morris SS, Bryce J. Where and why are 10 million children dying every year? Lancet 2003; \n361: 2226-34 \n7.  WHO. Effect of breastfeeding on infant and child mortality due to infectious diseases in less \ndeveloped countries: a pooled analysis. Collaborative Study Team on the role of breastfeeding in the \nprevention of infant mortality. Lancet 2000; 355: 451-5 \n8. Edmond KM, Kirkwood BR, Amenga-Etego S, Owusu- Agyei S, Hurt LS. Effect of early infant feeding \npractices on infection-specific neonatal mortality: an investigation of the causal links with \nobservational data from rural Ghana. Am J ClinNutr2007; 86: 1126-31 \n9. Nutrition Sector. (2022). Infant and young child feeding survey: Host community, Cox’s Bazar, \nBangladesh.  \nhttps://rohingyaresponse.org/wp-content/uploads/2023/12/Final-Report-IYCF_Survey_Host-\ncommunity_Coxs-Bazar_Bangladesh_NOV-2022.pdf \n10. Taslima Arzu, Bappy, S.S., Hossain, M.A., Sujan, M.A.K., Islam, M. and Rashid, M.O. 2025. Impact \nAssessment of the Nutrition Project in Both the Rohingya Camps and Host Communities of Cox’s \nBazar, Bangladesh. Asian Journal of Food Research and Nutrition. 4, 3 (Jul. 2025), 1008–1022. \nDOI:https://doi.org/10.9734/ajfrn/2025/v4i3306 \n . CC-BY 4.0 International licenseIt is made available under a \n is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity.(which was not certified by peer review)preprint \nThe copyright holder for thisthis version posted November 19, 2025. ; https://doi.org/10.1101/2025.11.17.25340405doi: medRxiv preprint \n\n11. Taslima Arzu, Mohammad Abdus Satter, Dipak Kumar Paul, Md. Ariful Kabir Sujan, Syeda Absha \nJabin, Kanika Mitra, and Mowri Dhali, “Proximate analysis of low-cost locally produced weaning foods \nand their safety aspects, in comparison to imported weaning foods.” International Journal of Biological \nand Pharmaceutical Sciences Archive, 2024, 08(01), 057–065. Article DOI: 10.53771/ijbpsa.. \n2024.8.1.0065  \n12. Taslima Arzu, Ariful Kabir Sujan, Farha Matin Juliana, and Sabir Hossain, “Study of IYCF Indicators \non Practices and Knowledge of Mothers in Rural Areas.” American Journal of Public Health Research, \nvol. 6, no. 3 (2018): 130-133. doi: 10.12691/ajphr-6-3-1 \n13. Taslima Arzu, Md. Ariful Kabir Sujan, Dipak Kumar Paul, Tanvir Ahmad, Khondoker Rashna Gulshan, \nFarha Matin Juliana, and Md. Sabir Hossain, “Impact of Infant and Young Child Feeding (IYCF) \nCounseling on Practices and Knowledge of Mothers in Rural Areas.” World Journal of Nutrition and \nHealth, vol. 7, no. 1 (2019): 11-17. doi: 10.12691/jnh-7-1-3 \n14. Taslima Arzu, Ariful Kabir Sujan, Dipak Kumar Paul, Tanvir Ahmad, Farha Matin Juliana, and Sabir \nHossain, “Comparative Study of Growth Monitoring & Promotion of Children with Special Care (IYCF \nCounseling) and without Special Care.” American Journal of Food Science and Technology, vol. 7, \nno. 4 (2019): 104-112. doi: 10.12691/ajfst-7-4-1  \n15. Ten steps to successful Breastfeeding. UNICEF/WHO Baby Friendly Hospital Initiative (BFHI). \nInitiation of breastfeeding by breast crawl. Available at: http://breastcrawl.org/10steps.shtml \n16. Arzu, T., Sujan, M. A. K., & Hossain, M. S. (2017). Assessment of infant and young child feeding \nindicators with special emphasis on practices and knowledge of mothers in rural areas. International \nJournal of Science and Research, 6(10), 888–891.  \nhttps://www.ijsr.net/getabstract.php?paperid=ART20176925 \n17. Arzu, T., Sujan, M. A. K., Juliana, F. M., & Hossain, S. (2018). Study of IYCF indicators on practices \nand knowledge of mothers in rural areas. American Journal of Public Health Research, 6(3), 130–133. \nhttps://pubs.sciepub.com/ajphr/6/3/1/index.html  \n18. Arzu, T., Sujan, M. A. K., Paul, D. K., Ahmad, T., Gulshan, K. R., Juliana, F. M., & Hossain, M. S. \n(2019). Impact of infant and young child feeding (IYCF) counseling on practices and knowledge of \nmothers in rural areas. World Journal of Nutrition and Health, 7(1), 11–17.  \nhttps://pubs.sciepub.com/jnh/7/1/3/index.html \n19. Arzu, T. (2019, November 21–22). Impact of infant and young child feeding (IYCF) counselling on \npractices and knowledge of mothers in rural areas in Bangladesh. 17th International Conference on \nClinical Nutrition and Fitness , Singapore. Journal of Nutrition and Human Health, 3 , 19. \nhttps://www.alliedacademies.org/proceedings/impact-of-infant-and-young-child-feeding-iycf-\ncounselling-on-practices-and-knowledge-of-mothers-in-rural-areas-in-bangla-5767.html \n20. Arzu, T., Sujan, A. K., Paul, D. K., Ahmad, T., Juliana, F. M., & Hossain, S. (2019). Comparative study \nof growth monitoring & promotion of children with special care (IYCF counseling) and without special \ncare. American Journal of Food Science and Technology, 7 (4), 104–112. \nhttps://pubs.sciepub.com/ajfst/7/4/1/index.html\n \n21. Individual Counselling: One-On-One Talk Therapy.   \n22.  https://www.betterhelp.com/advice/counseling/individualcounselling - one-on-one-talk-therapy/   \n \n . CC-BY 4.0 International licenseIt is made available under a \n is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity.(which was not certified by peer review)preprint \nThe copyright holder for thisthis version posted November 19, 2025. ; https://doi.org/10.1101/2025.11.17.25340405doi: medRxiv preprint","source_license":"CC-BY-4.0","license_restricted":false}