Effect of nutrition assessment, counselling and support integration on mother- infant nutritional status, practices and health in Tororo and Butaleja districts, Uganda: A comparative non equivalent quasi experimental study

1 Effect of nutrition assessment, counselling and support 2 integration on mother- infant nutritional status, practices 3 and health in Tororo and Butaleja districts, Uganda: A 4 comparative non equivalent quasi experimental study 5 6 Samalie Namukose1, Gakenia Wamuyu Maina2, Suzanne N Kiwanuka1 Fredrick Edward Makumbi3 7 8 1 Department of Health Policy Planning and Management, School of Public Health, College 9 of Health Sciences, Makerere University, Kampala Uganda 10 2 Department of Community Health and Behavioural Sciences, School of Public Health, 11 College of Health Sciences, Makerere University, Kampala Uganda 12 3 Department of Epidemiology and Biostatistics, School of Public Health, College of Health 13 Sciences, Makerere University, Kampala Uganda 14 * [email protected] 15 16 Abstract 17 Background: Malnutrition remains a health challenge for women aged 15 to 49 years and their 18 infants. While Nutrition Assessment Counselling and Support (NACS) is considered a 19 promising strategy, evidence on its effectiveness remains scanty. This study assessed the effect 20 of comprehensive NACS package on the mother-infant practices, health and nutrition outcomes 21 in two districts in Eastern Uganda. 22 Methods: A comparative non equivalent quasi experimental design was employed with two 23 groups; Comprehensive NACS (Tororo) and Routine NACS (Butaleja). Pregnant mothers 24 were enrolled spanning various trimesters and followed through the antenatal periods and post- . CC-BY 4.0 International licenseIt is made available under a perpetuity. is the author/funder, who has granted medRxiv a license to display the preprint in(which was not certified by peer review)preprint The copyright holder for thisthis version posted December 21, 2023. ; https://doi.org/10.1101/2023.12.20.23300314doi: medRxiv preprint NOTE: This preprint reports new research that has not been certified by peer review and should not be used to guide clinical practice. 25 delivery for health and nutrition status. Infants were followed for feeding practices, health and 26 nutritional status at birth and weeks 6, 10, 14 and at month 6, 9 and 12 post-delivery. 27 Propensity score matching ensured study group comparability. The NACS effect was estimated 28 by nearest neighbour matching and the logistic regression methods. Statistical analysis utilised 29 STATA version 15 and R version 4.1.1. 30 Results: A total of 666/784 (85%) with complete data and were analysed (routine: 412, 31 comprehensive: 254). Both groups were comparable by mothers’ age, MUAC, prior antenatal 32 visits, meal frequency, micronutrient supplementation and instances of maternal headache, 33 depression and diarrhoea. However, differences existed in gestation age, income, family size, 34 education and other living conditions. 35 Comprehensive NACS infants exhibited higher infant birth weights, weight- for- age z-scores 36 at the 3 rd -6 th visits (p<0.001), length- for- age z scores at the 4 th -7 th visits (p<0.001) and 37 weight-for-length z-scores at the 3rd - 5th (p<=0.001) visits. Despite fewer episodes of diarrhoea 38 and fever, upper respiration infections were higher. 39 Conclusion: The comprehensive NACS demonstrated improved mother-infant nutritional and 40 other health outcomes suggesting the need for integrated and holistic care for better maternal, 41 infant and child health. 42 Keywords: Effect, nutrition assessment counselling and support, practices, health and nutrition 43 outcomes, mothers, infants. 44 45 . CC-BY 4.0 International licenseIt is made available under a perpetuity. is the author/funder, who has granted medRxiv a license to display the preprint in(which was not certified by peer review)preprint The copyright holder for thisthis version posted December 21, 2023. ; https://doi.org/10.1101/2023.12.20.23300314doi: medRxiv preprint 46 Introduction 47 48 Maternal and infant malnutrition is a significant global health concern with significant 49 implications on the overall health and well-being of both the mothers and their infants. The 50 Global Nutrition report of 2022 [1] indicated that 29.9% of women of reproductive age suffer 51 from anaemia while 9.1% of all women were underweight. The prevalence of low birth weights 52 was 14.6% among the newborns while 22%, 6.7% and 5.7% of children under 5 years were 53 stunted, wasted and overweight respectively. In the same report, Sub-saharan Africa was noted 54 to contribute to the highest burden of malnutrition with 32.6% of children under 5year stunted, 55 5.2% wasted and 4% overweight while anaemia among the women of reproductive age was 56 31.9%. According to the Uganda Demographic Health Survey (UDHS) of 2016 [2], the 57 prevalence of stunting among children under 5 years was 29% while underweight and wasting 58 was 11% and 4% respectively. Additionally, aneamia affects 32% of the women of 59 reproductive age. These surveys and reports indicate the persistent challenge of malnutrition 60 among the women of reproductive health and children calling for urgent need for intervention 61 and improvement. 62 Maternal nutrition is vital for the health and well being of both the mother and her developing 63 infant. Maternal interventions aimed at improving nutrition practices before pregnancy, during 64 pregnancy and lactation have been extensively studied for their potential to enhance maternal 65 and infant health down the line [3–7]. Well nourished and healthy mothers are more likely to 66 give birth to health babies, experience a healthy pregnancy and are less likely to experience 67 life-threatening complications during pregnancy [8,9]. 68 69 Several studies have demonstrated the positive impact of maternal interventions on the 70 nutrition practices and growth of infants particularly when implemented in a multi-sectoral 71 approach. For instance, implementation of a comprehensive range of interventions such as; 72 breastfeeding promotion, education and counselling, maternal mental health, women 73 empowerment, family planning, water, hygiene and sanitation, agricultural interventions has . CC-BY 4.0 International licenseIt is made available under a perpetuity. is the author/funder, who has granted medRxiv a license to display the preprint in(which was not certified by peer review)preprint The copyright holder for thisthis version posted December 21, 2023. ; https://doi.org/10.1101/2023.12.20.23300314doi: medRxiv preprint 74 shown promising results in reducing stunting rates [10]. Notable studies by Olutayo et al [11], 75 Nadia et al [12], Bhutta et al [13] emphasize the importance of these holistic interventions in 76 reducing stunting. However, it is important to consider the perspective put forth by 77 USAID/Advancing Nutrition [14] which argues against using stunting as a primary indicator 78 of success of short term or single interventions at individual. Instead, stunting should be 79 interpreted as a reflection of the population’s well-being. This view suggests a more 80 comprehensive assessment of interventions success focusing of multiple short and long term 81 causal factors to malnutrition instead of looking at the immediate outcomes. 82 Additionally, numerous studies have shown that Nutrition Counselling and education during 83 pregnancy significantly improve maternal-infant nutrition practices as well as the overall health 84 and nutritional status of both mothers and infants. Dearden et al [15] demonstrated a positive 85 effect of nutrition counselling and education on maternal meal frequency and diet 86 diversification. These findings align with a quasi- experimental study conducted by Kaleem et 87 al [16] which indicated that Antenatal Counselling improved the maternal dietary practices 88 and nutritional status. Similarly, a study by Perez-Escamilla et al [17] revealed a positive 89 effect of maternal counselling on maternal and infant health and nutrition outcomes including 90 birth weights and prevention of pre-term births. In contrast, Ghosh-Jereth et al [18] found that 91 the maternal dietary intake remained low and anaemia rates were high despite targeted 92 antenatal care including counselling at every visit. The authors attributed this lack of 93 improvement to the poor quality of counselling, a finding also echoed by Nsiah-Asamoah et al 94 [19] in their study on nutrition counselling interactions between the health workers and 95 caregivers. While some studies showed positive effect of maternal nutrition counselling on the 96 maternal-infant health and nutrition outcomes, contrasting findings indicate that the quality of 97 the counselling and how it is delivered can have negative impact on these outcomes. More 98 research is needed to bridge this gap and provide a clearer understanding on the effect of 99 delivery of a comprehensive package including counselling on the mother-infant health and 100 nutrition outcomes. . CC-BY 4.0 International licenseIt is made available under a perpetuity. is the author/funder, who has granted medRxiv a license to display the preprint in(which was not certified by peer review)preprint The copyright holder for thisthis version posted December 21, 2023. ; https://doi.org/10.1101/2023.12.20.23300314doi: medRxiv preprint 101 Therefore, providing high-quality health services, including preventive health services, 102 antenatal, maternity and postnatal services as well as early diagnosis and treatment of medical 103 conditions such as anaemia is crucial for improving women’s health. The World Health 104 Organisation (WHO) and the Ministry of Health, Uganda recommends a comprehensive 105 package of nutrition interventions to pregnant women for a positive outcome, including 106 counselling on healthy eating and physical activity, guidance on infant and young child feeding, 107 nutrition education on energy and protein intake, and daily iron and folic acid supplements. 108 The package also includes energy and protein dietary supplements and high-protein 109 supplements for the undernourished populations [20,21]. 110 Even before the release of the WHO guidelines in 2020, the Ministry of Health in Uganda had 111 been implementing NACS initiative, aiming to integrate nutrition into the health system and 112 consequently improving the health and nutrition practices and outcomes of the beneficiaries. 113 The NACS intervention package was tailored to the specific nutrition needs of the clients and 114 was in line with WHO’s recommendations on maternal nutrition care. Support was provided 115 to mothers and their children, covering aspects such as optimal maternal nutrition, diversified 116 diets, iron/folic acid supplementation, iodated salt consumption, deworming, malaria 117 prevention, and provision of antenatal care package and encouragement to attend all the 8 118 visits. Breastfeeding education emphasized early initiation, exclusive breastfeeding for 6 119 months, and extended breastfeeding. Mothers of older infants received guidance on 120 complementary feeding practices. Caregivers of sick children were advised on continued 121 breastfeeding. The community system offered ongoing health and nutrition care, including 122 livelihood and economic support to improve the health and nutrition outcomes. The 123 malnourished mothers received therapeutic foods [22]. 124 While existing literature has assessed the impact of vertical maternal interventions on the health 125 and nutritional status of mothers and infants, there is limited body of research on the effect of 126 broad integrated interventions, such as NACS on the health and nutrition outcomes of 127 beneficiaries. This study therefore, sought to assess the effect of comprehensive NACS 128 package on the health and nutrition practices and status of mothers and their infants in Tororo . CC-BY 4.0 International licenseIt is made available under a perpetuity. is the author/funder, who has granted medRxiv a license to display the preprint in(which was not certified by peer review)preprint The copyright holder for thisthis version posted December 21, 2023. ; https://doi.org/10.1101/2023.12.20.23300314doi: medRxiv preprint 129 and Butaleja districts in Eastern Uganda. We tested the hypotheses that there was no difference 130 in the maternal-infant health, nutrition practices and outcomes between the facilities which 131 integrated comprehensive NACS, verses those with routine NACS. The findings of this study 132 contribute to the growing body of evidence on the effectiveness of broad integrated 133 interventions on the health and nutrition outcomes of the beneficiaries and provide insights and 134 recommendations for scaling up the NACS approach. 135 Pathways on the effect of NACS integration in the health system on maternal and infant 136 health, nutrition practices, and outcomes 137 Integration of comprehensive NACS into the health system will result into an integrated 138 nutrition service delivery system which aims to foster a productive interaction between the 139 service providers and mothers. Based on the health belief model, service providers were 140 expected be motivated to impart knowledge and skills to mothers, enabling them take charge 141 of their own health and nutrition. Based on the health belief model, these empowered mothers 142 would then embrace optimal nutrition practices resulting in enhanced health and nutrition well- 143 being. Consequently, this positive change would improve the health and nutrition outcomes of 144 their infants, as illustrated in S1 Fig 145 Insert S1 Fig 146 147 Material and Methods 148 Study Design 149 The study used a comparative non-equivalent quasi-experimental design with two groups; 150 comprehensive NACS integration compared to routine NACS integration. 151 152 Study Setting and population . CC-BY 4.0 International licenseIt is made available under a perpetuity. is the author/funder, who has granted medRxiv a license to display the preprint in(which was not certified by peer review)preprint The copyright holder for thisthis version posted December 21, 2023. ; https://doi.org/10.1101/2023.12.20.23300314doi: medRxiv preprint 153 The study involved pregnant and lactating mothers, along with their respective infants. The 154 two hospitals selected for the study were Tororo Hospital as the comprehensive NACS and 155 Busolwe Hospital as the routine NACS. The hospitals were similar by level of facility, 156 ownership, funding, staffing norms, services provided and client load. Pregnant mothers in 157 various trimesters were enrolled and their health and nutrition status monitored at the antenatal 158 visits and post-delivery. Only women accessing antenatal care and residing in Tororo and 159 Butaleja were included. During post-delivery, infants were monitored for their feeding 160 practices, health and nutrition status till 12 months. 161 Mothers and infants were followed through the scheduled visits at their respective health 162 service points, which included, antenatal, labour suite/maternity, postnatal, children wards, 163 young child and ART clinics. 164 165 Comprehensive NACS versus routine service delivery 166 The comprehensive NACS package targeted both the health workers and mothers with their 167 infants. The support to the health workers included: five-day training in NACS and Health 168 Management Information System (HMIS) for nutrition in-service courses for staff at key health 169 contact points, such as antenatal clinics, maternity, postnatal clinics, young child and HIV 170 clinics; provision of anthropometric equipment, policy guidelines, job aides, information, 171 education and communication materials for mothers; mentorships/support supervision of 172 health staff to ensure quality service delivery; monitoring and reporting of nutrition 173 interventions; employing quality improvement support to address gaps in NACS 174 implementation; linking study subjects to community support structures for continuous 175 nutrition care and support; and collaborating with key stakeholders and the district health 176 management team to establish supervisory and support mechanisms for the intervention. 177 To the mothers and their infants, the package included: nutrition assessment and categorization 178 of the nutritional status; health and nutrition education on a diversified diet, recommended 179 antenatal clinic visits, iron/folic acid supplementation, water hygiene, and sanitation; maternal- . CC-BY 4.0 International licenseIt is made available under a perpetuity. is the author/funder, who has granted medRxiv a license to display the preprint in(which was not certified by peer review)preprint The copyright holder for thisthis version posted December 21, 2023. ; https://doi.org/10.1101/2023.12.20.23300314doi: medRxiv preprint 180 infant nutrition counselling; provision of therapeutic feeds to identified malnourished cases; 181 active follow-up of mother-baby pairs to ensure they receive the necessary nutrition services. 182 183 Routine service delivery 184 In the routine NACS setting, some elements of NACS were integrated into the regular health 185 care services provided such as growth monitoring and promotion for children, iron/folic acid 186 supplementation. To ensure comparability, staff at both study settings were trained in NACS 187 and HMIS for nutrition. They were provided with information, education and communication 188 materials to enhance their capacity in nutrition education and counselling. Subsequently, the 189 staff carried on with their services as per usual. The nutrition counselling placed a strong 190 emphasis on promoting the consumption of locally available foods for the management of 191 malnutrition. [23] 192 We determined the level of exposure to comprehensive verses routine NACS by closely 193 supervising the data collection process and enhancing documentation of both the services 194 rendered and the frequency with which the respondents accessed these services. 195 Sampling 196 The study employed purposive sampling approach, enrolling subjects who had given their 197 consent on a continuous basis until the desired sample size was attained. In both study settings, 198 the antenatal care clinic served as the entry point and the ANC register as the sampling frame. 199 The enrolment of the study participants took 8 months from starting from 23rd October 2018 to 200 25th May, 2019. The mothers were followed up till they gave birth, and the mother-infant pairs 201 followed up for 12 months. Data was collected from 23rd October, 2018 to 25th July 2021. 202 . CC-BY 4.0 International licenseIt is made available under a perpetuity. is the author/funder, who has granted medRxiv a license to display the preprint in(which was not certified by peer review)preprint The copyright holder for thisthis version posted December 21, 2023. ; https://doi.org/10.1101/2023.12.20.23300314doi: medRxiv preprint 203 204 Sample size calculation 205 The sample size was calculated using the formular by V. Kasiulevicius et al [24] based on 206 infant underweight as an outcome variable. 207 n = [zα (1+ 1 m) p(1― p) + zβ po(1―p0) m + p1(1―p1) ]2 (p0 ― p1)2 208 Where p = p1 + mp0 m + 1 209 Where, 210 P0 was the probability of underweight infants in the control group – 0.113. 211 P1was the probability of underweight infants in the intervention group – 0.07 212 P0 was based on the Uganda Demographic Health Survey 2011 burden of malnutrition in the 213 eastern region while P1 was an estimated reduction in underweight with the intervention. 214 If α (alpha) = 0.05 then zα = 1.96 215 If β (beta) = 0.80, then zβ = 0.845 216 m was the number of control subjects per experimental subject = 2 217 p = 0.0987 218 n = 652 with the inclusion of 20% loss to follow up of mother-baby pairs. A sample size of 652 219 (217 in the intervention group and 435 in the control group) was estimated to detect a 4.3% 220 reduction in the underweight infants at 80% power and 5% level of significance. 221 222 Data collection 223 We pre-tested the data collection tools among the mothers and feedback was used to finalize 224 the tools. The tool was designed in excel to facilitate the tracking of the mother- baby variables 225 for their scheduled visits. 226 Our research assistants underwent training on the data collection tools and data capture 227 methods at a minimum of four points: recruitment/baseline, antenatal clinic visits, delivery and 228 postnatal care clinic, and immunization scheduled visits. We encouraged mothers to deliver at 229 the health facility where they were provided with a package of both routine and comprehensive 230 package of services. To ensure data quality, we conducted regular supervision and spot checks. 231 232 . CC-BY 4.0 International licenseIt is made available under a perpetuity. is the author/funder, who has granted medRxiv a license to display the preprint in(which was not certified by peer review)preprint The copyright holder for thisthis version posted December 21, 2023. ; https://doi.org/10.1101/2023.12.20.23300314doi: medRxiv preprint 233 At baseline/recruitment, we collected data on various aspects, including socio-economic and 234 demographic characteristics, maternal health and nutrition practices, and maternal nutritional 235 status. Throughout each antenatal visits, we monitored the mothers’ anthropometric data, 236 health status and nutrition practices. Following delivery, we collected data on infant’s 237 anthropometric measurement such as birth weight, length, head circumference as well as details 238 about their feeding practices. Subsequently, we continued to track the infants’ anthropometric 239 data, health and nutrition practices and status during the scheduled immunization visits. 240 Anthropometric data and feeding practices for both the mother and her infant were collected 241 using standard procedures. Mother’s weight was taken to the nearest 0.1gm using a digital 242 Uniscale. The infant weight was measured to nearest 0.1 gm using the neonatal weighing scales 243 at birth and thereafter a digital uniscale. Infant length was measured to nearest 0.1cm using an 244 infantometer at birth and a height board for the subsequent visits. 245 We measured the head circumference and Mid Upper Arm Circumference (MUAC) of infants 246 using specialized tapes, with measurements recorded to the nearest 0.1cm. MUAC was 247 measured for infants above 6 months and mothers. Additionally, we conducted health 248 assessment for mothers, including evaluation for illnesses such as headaches, depression, 249 diarrhea, fever and cough. For infants, we assessed episodes of diarrhea, fever and Upper 250 Respiratory infections. 251 In total, there were 15 scheduled appointments from the time of mother’s enrolment until the 252 baby made 12 months of age. Mothers were encouraged to continue attending health facilities 253 for continuous health care as well as participating in the informative health and nutrition 254 education sessions. 255 256 Data management 257 We used excel for data capture, STATA version 15 for data, cleaning and performing bivariate 258 tests on all confounding background variables for both study settings. The variables included; 259 weeks of gestation, age of the mothers, mothers’ education, marital status, mothers’ occupation, . CC-BY 4.0 International licenseIt is made available under a perpetuity. is the author/funder, who has granted medRxiv a license to display the preprint in(which was not certified by peer review)preprint The copyright holder for thisthis version posted December 21, 2023. ; https://doi.org/10.1101/2023.12.20.23300314doi: medRxiv preprint 260 mothers’ income, spouses’ income, spouses’ education level, previous ANC visits, distance to 261 the health facility, type of transport used, total numbers of children, number of children alive, 262 number of family members, number of children under 5 years, fuel for cooking, water source 263 and faecal matter disposal. We cleaned data by synchronising the variable codes for the two 264 data sets, checked for missing data, and excluded the variables with insignificant data. 265 We characterised variables as continuous, binary, categorical and generated new variables. We 266 checked the data set for normal distribution for the continuous variables. Descriptive analysis 267 was conducted to compare mothers’ background characteristics in the 2 study arms. Continuous 268 variables were compared using a 2 sample t-test while the categorical variables were compared 269 using the chi square test. 270 Data analysis 271 Because these groups were not randomly assigned and this being a quasi non- equivalent 272 experimental study, we conducted propensity score matching to minimise potential imbalance 273 and also create reasonable comparable groups, before assessment of the effectiveness of the 274 NACS intervention. 275 By creating more comparable intervention and control groups, propensity score matching can 276 result into a more precise estimates of intervention effects and reducing confounders. On the 277 other hand, matching reduces the sample size, because not all individuals may find suitable 278 matches resulting in a loss of statistical power and precision [25–27]. 279 The propensity score matching process involved; defining the intervention (comprehensive 280 NACS) verses control (routine NACS) groups, identification of the variables before 281 administration of the intervention, estimating the propensity scores, checking the initial balance 282 of the variables for both groups using mean differences, using the nearest-neighbor matching 283 method to pair individuals in intervention and control group based on their propensity scores, 284 assessing the quality of the matches, and thereafter estimating the effect of comprehensive 285 NACS on maternal-infant practices, health and nutritional status [27]. . CC-BY 4.0 International licenseIt is made available under a perpetuity. is the author/funder, who has granted medRxiv a license to display the preprint in(which was not certified by peer review)preprint The copyright holder for thisthis version posted December 21, 2023. ; https://doi.org/10.1101/2023.12.20.23300314doi: medRxiv preprint 286 Using the R software version 4.1.1, we estimated the NACS effect on maternal-infant nutrition 287 practices, health and nutritional status by comparing various methods such as nearest 288 neighbour, null and full matching methods. The nearest neighbour matching using the logistic 289 regression propensity score model provided the best balance compared to other matching 290 methods such as; full matching using a probit regression propensity score, nearest neighbour 291 matching using a probit regression propensity score, null probit, full matching using a logistic 292 regression propensity score as determined by the lower standardised mean difference statistics. 293 The enrolment and data analysis flow chart is illustrated in S2 Fig. 294 Insert S2 Fig 295 Ethical approval 296 This study was approved by: the Higher Degrees, Research, and Ethics Committee – 297 Institutional Review Board at Makerere University School of Public Health (MaKSPH 298 HDREC 24/01/2017), the Uganda National Council of Science and Technology (SS 4251), and 299 the Office of the President in Uganda (ADM/194/212/01). An official letter from the Ministry 300 of Health was written to the Tororo District Health Officer to seek for permission to conduct 301 the study. The Principal Investigator informed both the District Health Officer and the District 302 Resident Commissioner about the study plan before its execution. Participating mothers were 303 asked to sign informed consent form. The mothers who were unable to read and write provided 304 their informed consent using their thumbprint. 305 . CC-BY 4.0 International licenseIt is made available under a perpetuity. is the author/funder, who has granted medRxiv a license to display the preprint in(which was not certified by peer review)preprint The copyright holder for thisthis version posted December 21, 2023. ; https://doi.org/10.1101/2023.12.20.23300314doi: medRxiv preprint 306 Results 307 A total of 784 mothers were enrolled in the study; 423 from the Routine NACS setting and 361 308 from the Comprehensive NACS setting. One hundred (118) mothers were excluded from the 309 analysis due to missing data while 666 mothers were considered in the final analysis, majority 310 from the routine (412) compared to comprehensive (254) NACS groups. 311 The mothers’ characteristics at enrollment were compared in the two study arms and the results 312 are shown in the Tables 1 and 2. The findings indicated no significant difference between the 313 mother’s age (p= 0.466), prior antenatal visits for this pregnancy (p=0.316), number of family 314 members (p=0.007) between the two groups at enrollment. However, there was a significant 315 difference in the weeks of gestation (p=0.023), mothers’ income (p=0.000), spouses’ income 316 (p=0.000), number of children (p=0.000), number of children alive (p=0.000), number of children 317 < 5years (p=0.001), distance to health facility (p<0.001), mothers’ education (p<0.001), marital 318 status (p<0.001), mothers’ occupation (p<0.001), spouses’ education (p<0.001), type of transport 319 (p<0.001), cooking method (p<0.001), water source (p<0.001), and fecal matter disposal 320 (p<0.001). 321 Table 1. Mothers’ characteristics at enrolment in the routine verses comprehensive study arms for 322 continuous variables Variable name (Comprehensive NACS=254, Routine NACS = 412) t-test p-value Mothers’ age -0.730 0.466 Weeks of gestation 2.277 0.023 Mothers’ income -4.682 0.000 Spouse income -4.997 0.000 Prio antennal visits for this pregnancy 1.003 0.316 Number of children 11.400 0.000 Number of children alive 5.725 0.000 Number of family members 2.669 0.007 Number of children less than 5 years 6.842 0.000 323 324 . CC-BY 4.0 International licenseIt is made available under a perpetuity. is the author/funder, who has granted medRxiv a license to display the preprint in(which was not certified by peer review)preprint The copyright holder for thisthis version posted December 21, 2023. ; https://doi.org/10.1101/2023.12.20.23300314doi: medRxiv preprint 325 Table 2. Mothers’ characteristics at enrolment in the routine verses comprehensive NACS 326 study arms for categorical variables before propensity score matching 327 328 Variable name Routine NACS N=412 Comprehensive NACS N=254 Chi-square Test (p-Value) Distance to health facility 5 km 96.1% 3.9% 60.6% 39.4% <0.001 Mothers Education No Education Primary Secondary Higher 5.8% 62.9% 26.9% 4.4% 1.2% 44.9% 40.6% 13.4% <0.001 Marital Status Married Not married 94.4% 5.6% 99.6% 0.4% <0.001 Mothers occupation Formal Informal 6.8% 93.2% 18.1% 81.9% <0.001 Spouse’s education No Education Primary Secondary Higher 4.2% 49.3% 38.7% 7.8% 1.2% 25.6% 55.1% 18.1% <0.001 Type of transport Motorised Walking 50.7% 49.3% 92.1% 7.9% <0.001 Cooking method Firewood Charcoal Gas 79.9% 19.9% 0.2% 52.8% 46.1% 1.2% <0.001 Water source Well Borehole Tap water 0.2% 96.8% 2.9% 16.1% 44.1% 39.8% <0.001 Faecal matter Disposal Latrine Toilet 99.3% 0.7% 89.0% 11.0% <0.001 . CC-BY 4.0 International licenseIt is made available under a perpetuity. is the author/funder, who has granted medRxiv a license to display the preprint in(which was not certified by peer review)preprint The copyright holder for thisthis version posted December 21, 2023. ; https://doi.org/10.1101/2023.12.20.23300314doi: medRxiv preprint 329 Propensity score matching was used to create comparability between the study groups. The Null 330 model was used to check the initial imbalance in the two groups that the matching methods 331 eliminated step wise. Table 3 shows severe imbalances as reflected by the standard mean 332 differences computed by the R software. All values close to zero in the standard mean differences 333 reflected better matches while those away from zero reflected severe imbalances. The variable 334 ‘number of children’ had the highest difference (-4.7263) indicating severe imbalance while the 335 variable ‘nutrition status by MUAC’ had the lowest difference (0.0019) indicating that mothers in 336 the both groups had comparable nutritional status, which conclusions resonate with exiting 337 literature [28]. 338 Table 3: Propensity score matching null model for checking initial imbalance between the 339 comprehensive and routine NACS study arms Variables Means Treated Means Control Mean difference Distance 0.8513 0.1053 3.1896 Mother age 15-24 25-49 0.4762 0.5238 0.5140 0.4860 -0.0758 0.0758 Mothers’ education 1. No Education 2. Primary 3. Secondary 4. Higher 0.0119 0.4444 0.4087 0.1349 0.0562 0.6433 0.2556 0.0449 -0.4082 -0.4001 0.3115 0.2634 Marital status 1. Married 2. Not Married 0.9960 0.0040 0.9438 0.0562 0.8305 -0.8305 Mothers’ occupation 1. Formal 2. Informal 0.1825 0.8175 0.0674 0.9326 0.2980 -0.2980 Spouse education 1. No Education 2. Primary 3. Secondary 4. Higher 0.0119 0.2579 0.5476 0.1825 0.0365 0.5056 0.3820 0.0758 -0.2269 -0.5661 0.3327 0.2762 Prior ANC visits 2.0397 2.1011 -0.0626 Distance to hospital 1. Less than 5km 2. ≥ 5km 0.6111 0.3889 0.9635 0.0365 -0.7228 0.7228 Type of transport 1. Walking 2. Motorized 0.0794 0.9206 0.5028 0.4972 -1.5665 1.5665 No. of children 1.0198 2.6236 -4.7263 No. of children alive 1.5437 2.4129 -0.5786 No of chn < 5years 0.7540 1.2809 -0.6142 Type of fuel used 1. Firewood 2. Charcoal 3. Gas 0.5278 0.4603 0.0119 0.7978 0.2022 0.0000 -0.5408 0.5178 0.1098 . CC-BY 4.0 International licenseIt is made available under a perpetuity. is the author/funder, who has granted medRxiv a license to display the preprint in(which was not certified by peer review)preprint The copyright holder for thisthis version posted December 21, 2023. ; https://doi.org/10.1101/2023.12.20.23300314doi: medRxiv preprint Water source 1. Well 2. Borehole 3. Tap Water 0.1627 0.4405 0.3968 0.0028 0.9691 0.0281 0.4332 -1.0648 0.7537 Faecal matter disposal 1. Latrine 2. Toilet 0.8889 0.1111 0.9916 0.0084 -0.3267 0.3267 Mother wtg (kg) 1st visit 64.2496 60.7542 0.3124 Nutritional status by MUAC 1. Normal (Green) 2. Malnourished (Yellow/Red) 0.9722 0.0278 0.9719 0.0281 0.0019 0.0019 No. of meals 3.0992 2.8792 0.2940 Iron folic acid supplement No 0.0238 0.0028 0.1377 Yes 0.9762 0.9972 -0.1377 History of headache No Yes 1.0000 0.0000 0.8034 0.1966 0.6465 -0.6465 History of depression No Yes 1.0000 0.0000 0.9803 0.0197 0.1851 -0.1851 History of diarrhoea No Yes 1.0000 0.0000 0.9888 0.0112 0.1393 0.1393 History of fever No Yes 0.9960 0.0040 0.9298 0.0702 1.0539 -1.0539 History of cough No Yes 1.0000 0.0000 0.9522 0.0478 0.2927 -0.2927 340 341 Effect NACS integration on the mothers-infant health, nutrition practices and 342 status 343 The study assessed the effect of NACS integration on maternal-infant nutrition practices as well 344 as its effects on health and nutritional status. This assessment employed the nearest neighbour 345 matching method along with a logistic regression propensity score model and the results are shown 346 in Table 4. 347 348 . CC-BY 4.0 International licenseIt is made available under a perpetuity. is the author/funder, who has granted medRxiv a license to display the preprint in(which was not certified by peer review)preprint The copyright holder for thisthis version posted December 21, 2023. ; https://doi.org/10.1101/2023.12.20.23300314doi: medRxiv preprint 349 Table 4. The effect of NACS integration on the mother-infant nutrition practices, health and 350 nutrition status using nearest neighbour matching logistic regression propensity score model 351 Variable name Contrast 1-(Comp NACS) 0-(Routine NACS) Estimate SE P value CI Mother variables N=252 N=252 Meal frequency at 2nd visit 1 0 0.008 0.070 0.911 -0.13, -0.146 Diet Diversity Score 2nd visit 1 0 -3.110 0.263 <0.001 -3.630, - 2.600 3rd visit 1 0 -2.980 0.213 <0.001 -3.400, -2.560 4th visit 1 0 -2.690 0.149 <0.001 2.990, -2.400 Iron/ folic acid supplementation 2nd visit 1 0 -0.029 0.010 0.006 -0.049, -0.008 3rd visit 1 0 -0.024 0.010 0.012 -0.043 , -0.005 4th visit 1 0 -0.035 0.015 0.017 -0.064 , -0.006 Weight at 2nd visit 1 0 1.040 0.272 <0.001 0.507 -1.570 3rd visit 1 0 2.690 0.422 <0.001 1.860 – 3.520 4th visit 1 0 5.860 1.990 0.003 1.950 – 9.760 Nut.status by (MUAC) 2nd visit 1 0 0.038 0.018 0.032 0.003- 0.072 3rd visit 1 0 0.026 0.009 0.047 0.008 -0.044 4th visit 1 0 0.025 0.015 0.091 0.004- 0.054 History of headache 2nd visit 1 0 0.020 0.009 0.020 0.003 - 0.037 3rd visit 1 0 0.044 0.013 <0.001 0.020- 0.069 4th visit 1 0 0.078 0.022 <0.001 0.034 - 0.121 History of depression 2nd visit 1 0 0.013 0.007 0.070 -0.001, -0.026 3rd Visit 1 0 0.008 0.005 0.160 -0.003, -0.018 Diarrhoea at 3rd visit 1 0 0.018 0.008 0.030 0.002 -0.034 History of fever 2nd visit 1 0 0.020 0.009 0.019 0.003 - 0.037 3rd visit 1 0 0.049 0.014 <0.001 0.023 - 0.076 4th visit 1 0 0.030 0.013 0.021 0.005 - 0.055 Infant variables Infant birth weight 1 0 0.191 0.100 0.056 -0.005, -0.387 Infant weight at 3rd visit 1 0 1.050 0.111 <0.001 0.835 - 1.270 4th Visit 1 0 1.130 0.106 <0.001 0.923 - 1.340 5th visit 1 0 1.930 0.107 <0.001 1.720 - 2.140 . CC-BY 4.0 International licenseIt is made available under a perpetuity. is the author/funder, who has granted medRxiv a license to display the preprint in(which was not certified by peer review)preprint The copyright holder for thisthis version posted December 21, 2023. ; https://doi.org/10.1101/2023.12.20.23300314doi: medRxiv preprint Infant head cirm 3rd visit 1 0 3.900 0.248 <0.001 3.410 - 4.380 4th visit 1 0 3.900 0.248 <0.001 3.410 - 4.380 5th visit 1 0 0.020 0.009 0.019 0.003 -0.037 Wt for Age Z-scores 3rd visit 1 0 1.800 0.233 <0.001 1.350-2.260 4th visit 1 0 1.700 0.208 <0.001 1.290 -2.110 5th visit 1 0 2.730 0.202 <0.001 2.330 – 3.130 6th visit 1 0 0.265 0.159 0.096 -0.047, -0.577 Length for Age Z- scores 4th visit 1 0 0.634 0.246 0.010 0.151 – 1.120 5th Visit 1 0 0.761 0.222 <0.001 0.326 – 1.200 6th visit 1 0 3.990 0.281 <0.001 3.440 – 4.540 7th visit 1 0 4.630 1.140 <0.001 2.470 – 6.780 Wt. for Length Z- scores at 3rd visit 1 0 6.250 0.475 <0.001 5.320 – 7.180 4th visit 1 0 1.460 0.356 <0.001 0.763 – 2.160 5th visit 1 0 2.770 0.342 <0.001 2.100 – 3.440 History of Upper Respiratory Infection 5th Visit 1 0 0.043 0.013 <0.001 0.018 - 0.069 6th visit 1 0 0.155 0.023 <0.001 0.110 - 0.199 7th visit 1 0 0.294 0.029 <0.001 0.237 - 0.350 8th visit 1 0 0.315 0.029 <0.001 0.258 - 0.372 History of infant diarrhoea 5th visit 1 0 -0.168 0.080 0.036 -0.324, -0.011 6th visit 1 0 -0.146 0.080 0.067 -0.302- 0.010 7th visit 1 0 -0.033 0.049 0.506 -0.130- 0.064 8th visit 1 0 -0.126 0.067 0.061 -0.130- 0.064 History of infant fever 1st visit 1 0 -0.054 0.030 0.072 -0.113- 0.005 3rd visit 1 0 -0.005 0.012 0.694 -0.029- 0.019 4th visit 1 0 -0.409 0.086 <0.001 -0.576, -0.241 5th Visit 1 0 -0.111 0.076 0.145 -0.260- 0.038 6th visit 1 0 -0.023 0.062 0.712 -0.144 - 0.099 7th visit 1 0 0.028 0.050 0.569 -0.070 - 0.126 8th visit 1 0 -0.027 0.060 0.657 -0.143- 0.090 352 353 354 Mothers in both groups were similar in terms of; meal frequency (p=0.911), iron/folic acid 355 supplementation at the 2nd -4th visits (β <= -0.035), maternal nutritional status by MUAC at the 356 2nd – 4 th visits (β<= 0.038). Additionally there was no significant difference in maternal . CC-BY 4.0 International licenseIt is made available under a perpetuity. is the author/funder, who has granted medRxiv a license to display the preprint in(which was not certified by peer review)preprint The copyright holder for thisthis version posted December 21, 2023. ; https://doi.org/10.1101/2023.12.20.23300314doi: medRxiv preprint 357 instances of; headache at the 2 nd -4 th visits (β<=0.078), depression at the 2 nd -3 rd visit 358 (β<=0.013) and diarrhoea at the 2nd -4th (β<=0.049) visits. 359 Whereas mothers in the routine NACS group had a significantly higher diversity score at the 360 2nd - 4th visits (p<0.001), the comprehensive group had higher weights at the 2nd - 4th (p<=0.003) 361 visits. The difference in weights increased with number of visits right from the time of mothers’ 362 enrolment. 363 Compared to routine, infants born to mothers in the comprehensive group had a significantly 364 higher; birth weights at 10% level of significance (p=0.056, CI -0.005 – 0.387), weight-for- 365 age at the 3 rd -6 th visits (p<0.001) with 20% reduction in underweight on average per visit. 366 Furthermore, their length-for-age was significantly higher at the 4 th -7th visits (p<0.001). The 367 difference widened with the increasing number of visits. Similarly, the weight-for-length of the 368 comprehensive NACS group was significantly much higher at the 3rd -5th visits (p<0.001). The 369 difference remained constant throughout the subsequent visits. 370 Unlike the routine group, infants in the comprehensive NACS group had significantly higher 371 episodes of upper respiratory infections at the 5th -8th (p<0.001, β<=0.315). On the other hand, 372 the routine NACS infants experienced a significantly higher episodes of; diarrhoea at the 5 th - 373 8th visits (p<=0.061) and fever at the 1st (p=0.072, β=-0.054) and 4th visits (p<0.001, β=-0.409). 374 375 376 377 . CC-BY 4.0 International licenseIt is made available under a perpetuity. is the author/funder, who has granted medRxiv a license to display the preprint in(which was not certified by peer review)preprint The copyright holder for thisthis version posted December 21, 2023. ; https://doi.org/10.1101/2023.12.20.23300314doi: medRxiv preprint 378 Discussion 379 The study aimed to assess the effect of NACS integration on the maternal-infant nutrition 380 practices, health and nutritional status. The findings provide insights into the potential benefits 381 of nutrition integration on the health system on the wellbeing of the mothers and their infants. 382 The key findings in light of existing evidence and their implication are discussed. 383 The study found no significant difference in meal frequency among the mothers in both study 384 groups, suggesting similar dietary habits. Compared to the comprehensive group, mothers in 385 the routine NACS setting had a significantly higher diversity scores on all visits. This disparity 386 may be attributed to the close proximity to the rural settings offering more natural and diverse 387 food choices. Maternal nutritional status by MUAC estimates exhibited no significant 388 differences across the visits in the two study settings. In contrast to the routine group, mothers 389 in the comprehensive displayed significantly higher weights at the 2nd- 4th visits. This implied 390 that integration of comprehensive NACS had positive progressive impact on maternal weight 391 gain from the time of enrolment. The findings suggest potential program implication and 392 highlight the need to consider environmental context when implementing nutrition programs. 393 Future nutrition interventions should therefore be tailored to the specific needs and context of 394 the target population. Furthermore, the study re-enforces, existing body of evidence indicating 395 that maternal focused interventions particularly those with a multi-sectoral nature contribute to 396 improved maternal diet diversity, micronutrient intake and overall nutritional status [29–31]. 397 Additionally, there were minimal difference in iron/folic acid supplementation between the two 398 groups at the 2 nd - 4th visits implying consistent adherence to the Ministry of Health guidance 399 on routine iron/folic acid supplementation among pregnant mothers in both settings. However, 400 it is worth noting that the effect of iron/folic acid supplementation on haemoglobin levels in 401 both settings could not be assessed in both settings due to lack of equipment and supplies. 402 Studies by Michael Habtu et al [32], Sunita Taneja et al [7], Melesse Kuma et al [33] revealed 403 elevated haemoglobin levels among women in the intervention group, findings that our study 404 was unable to replicate due to the constraints related to equipment and supplies. . CC-BY 4.0 International licenseIt is made available under a perpetuity. is the author/funder, who has granted medRxiv a license to display the preprint in(which was not certified by peer review)preprint The copyright holder for thisthis version posted December 21, 2023. ; https://doi.org/10.1101/2023.12.20.23300314doi: medRxiv preprint 405 The estimates showed no difference between the two settings for maternal episodes of 406 headache, depression and diarrhoea across the various visits. This implies that these health 407 concerns are common and not influenced by the study settings. These need to be addressed in 408 both setting for the well being of mothers. 409 Our investigation into the nutritional status of the infants revealed that integration of 410 comprehensive NACS increased infant birth weights, reduced instances of underweight, 411 stunted and wasted infants. This implies that nutrition integration had a potential benefit of on 412 the foetal and infant growth and development. Our findings concur with; Veeena et al [34] M 413 Barker et al [8] , Von Salmuth et al [10], Olutayo et al [11], Micheal Habtu etal [35] on the 414 effectiveness of a holistic approach to improving the nutritional status of children. 415 Routine NACS infants experienced significantly more episodes of diarrhea and fever at the 416 various visits than the comprehensive NACS group. The findings concur with Gonzalenz- 417 Fernandez et al [36] in their study in which implementation of the multisectoral approach 418 lowered the risk of diarrhoea and respiratory infections. This implies that the health facilities 419 in the routine NACS settings did not comprehensively address these health concerns hence the 420 need for more interventions for better health and nutrition outcomes. 421 One of the strengths of this study lies in its comparison of two separate groups; routine versus 422 comprehensive and its close monitoring of the practices and outcomes of the study participants. 423 This approach bolstered the study's findings, providing a clear and robust insight into the 424 effectiveness of the integrated intervention package. Moreover the study places emphasis on 425 favourable outcomes of comprehensive NACS highlighting the potential benefits of such 426 comprehensive interventions, which findings are also consistent with the existing literature. On 427 the other hand, the study lacked the ability to assess the impact of iron/folic acid 428 supplementation on haemoglobin levels due to lack of equipment and supplies, which is a 429 limitation in understanding the complete maternal health and nutrition outcomes. . CC-BY 4.0 International licenseIt is made available under a perpetuity. is the author/funder, who has granted medRxiv a license to display the preprint in(which was not certified by peer review)preprint The copyright holder for thisthis version posted December 21, 2023. ; https://doi.org/10.1101/2023.12.20.23300314doi: medRxiv preprint 431 Conclusions 432 The findings add to the existing body of evidence supporting improved maternal-infant health 433 and nutrition practices and status with integrated nutrition services. While meal frequency, 434 iron/folic acid supplementation were similar in the both groups, integration of comprehensive 435 NACS intervention improved; maternal weights, infant birth weights, infant growth in light of 436 weight-for-age, length-for-age and weight-for-length. This emphasises the potential benefits of 437 integrated nutrition interventions in promoting the overall being of the mothers and their 438 infants. 439 Recommendations 440 Based on the above findings, the Ministry of Health should consider: investing in acquiring 441 the necessary equipment and supplies to assess the impact of iron/folic acid supplementation 442 on haemoglobin levels for comprehensive evaluation of the women; scaling up integration of 443 the comprehensive NACS in the health system as it has positive effect on the maternal-infant 444 nutrition practices, health and nutrition outcomes; investing in digitization to ease monitoring 445 and tracking trends in the health and nutrition status of the mother-infant pairs. 446 Future research can focus on implementation and effectiveness of digitization in monitoring 447 and tracking of the maternal-infant health and nutritional status in an integrated health system. 448 Secondly, it will be important to investigate the experiences of the women and caregivers 449 receiving these services. 450 . CC-BY 4.0 International licenseIt is made available under a perpetuity. is the author/funder, who has granted medRxiv a license to display the preprint in(which was not certified by peer review)preprint The copyright holder for thisthis version posted December 21, 2023. ; https://doi.org/10.1101/2023.12.20.23300314doi: medRxiv preprint 451 Supporting information 452 S1 File Dataset for Tororo and Butaleja districts 453 S1 Fig. Pathways on the effect of NACS integration into the health system on maternal and 454 infant health, nutrition practices, and outcomes adapted from the Chronic Care Model 455 S2 Fig. Enrolment and data analysis flow chart 456 Acknowledgements 457 We extend our appreciation to the political and administrative authorities of Tororo and 458 Butaleja districts for granting us the necessary permission to conduct this study. Our gratitude 459 go to the health workers as well as the mothers and their infants from Tororo and Butaleja 460 districts for the dedicated participation in advancing this research undertaking. Brian Wakoli 461 is appreciated for the statistical support rendered during the analysis. 462 Author contribution 463 Conceptualization: SN FEM GWM SNK 464 Data Curation: SN FEM SNK 465 Formal analysis: SN SNK FEM 466 Funding acquisition: SN 467 Investigation: SN 468 Methodology: SN SNK FEM 469 Project administration: SN 470 Resources: SN 471 Software: SN 472 Supervision: SN FEM GWM SNK 473 Validation: SN FEM GWM SNK 474 Visualization: SN FEM 475 Writing- Original draft: SN . 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