Title: Nutritional effects of a home-based participatory play intervention: results from a randomized

evaluation in El Alto, Bolivia

Article Type: Article (Randomized Trial)

Corresponding Author: Sebastian Martinez, PhD

Corresponding Author’s Institution: Inter-American Development Bank

First Author: Sebastian Martinez

Order of Authors: Sebastian Martinez, Julia Johannsen, Gaston Gertner, Jorge Franco, Ana B Perez-
Expósito, Rosario M Bartolini, Irma Condori, Jhovanna Flores Ayllón, Ramiro Llanque, Nohora
Alvarado, Christian Lunstedt, Cecilia Ferrufino, Teresa Reinaga, Mauricio Chumacero, Carlos Foronda,
Santiago Albarracin, Ana Maria Aguilar

Funding: Baseline data collection and part of the program’s implementation costs were funded with
Inter-American Development Bank (IDB) grant BO-T1181 (ATN/JO-13606-BO), “Improving Child
Nutrition Services in Bolivia,” a technical cooperation project financed through a donation from the
IDB’s Japan Special Fund Poverty Reduction Program (JPO) and executed by the CSRA, in coordination
with the Ministry of Health and local public health centers in El Alto. Endline data collection was
conducted by the Center for Generation of Information and Statistics (CEGIE) at the Bolivian Private
University and funded through the IDB grant BO-T1259 (ATN/OC-15554-BO), “Effectiveness Of
Community Interventions to Reduce Child Malnutrition,” executed by the IDB. The authors declare no
financial interests in the results of the study.

Ethics Committee Approval: The survey was reviewed and approved by the ethical review board of the
National Bioethics Committee in Bolivia. Informed consent was obtained from the infants’ parents or
guardians prior to data collection, and the rights to access study data were restricted to maintain
confidentiality.

Authors Contributions: Sebastian Martinez (SM), Julia Johannsen (JJ), Gaston Gertner (GG), Jorge
Franco (JF), Ana B Perez-Expósito (APE), Rosario M Bartolini (RB), Irma Condori (IC), Jhovanna
Flores Ayllón (JFA), Ramiro Llanque (RL), Nohora Alvarado (NA), Christian Lunstedt (CL), Cecilia
Ferrufino (CF), Teresa Reinaga (TR), Mauricio Chumacero (MC), Carlos Foronda (CF), Santiago
Albarracin (SA), Ana Maria Aguilar (AA).
Conceived and designed the study: SM, JJ, GG, APE, RB, IC, RL, AA
Wrote the paper: SM, JJ, GG, JF, APE, RB, IC, JFA, RL, NA, CL, CF, TR, MC, CF, SA, AA
Discussed, critically revised, and approved the study protocol: SM, JJ, GG, APE, RB, IC, RL, AA
Responsible for the organization and conduct of the study: SM, JJ, GG, RB, IC, JFA, RL, NA, CL, CF,
TR, AA
Supervised the study: SM, JJ, GG, NA, CL, TR, AA
Collected data: TR, MC, CF, SA
Responsible for the statistical analysis: SM, JF
Contributed to data analysis: JJ, GG, APE, RB, AA
Drafted the first version of the report: SM, JJ, GG, JF, APE, RB, IC, JFA, RL, NA, CL, CF, TR, MC, CF,
SA, AA
Elaborated, discussed, and approved the final version of the report and the paper for publication: SM, JJ,
GG, JF, APE, RB, IC, JFA, RL, NA, CL, CF, TR, MC, CF, SA, AA
 Nutritional effects of a home-based participatory play intervention: results from a
randomized evaluation in El Alto, Bolivia
Sebastian Martinez, Julia Johannsen, Gaston Gertner, Jorge Franco, Ana B Perez-Expósito, Rosario M Bartolini,
Irma Condori, Jhovanna Flores Ayllón, Ramiro Llanque, Nohora Alvarado, Christian Lunstedt, Cecilia Ferrufino,
Teresa Reinaga, Mauricio Chumacero, Carlos Foronda, Santiago Albarracin, Ana Maria Aguilar

Summary

Background: Stunting affects child survival and is a key indicator of child well-being. Therefore, reducing stunting is
a global goal. Improving infant feeding practices (IFPs) is a recommended approach to reduce the risk of mortality
and ameliorate nutritional status. Behavioral change interventions rapidly improve IFPs.

Methods: We evaluated the effectiveness of an innovative behavioral change strategy on caregiver’s knowledge, IFPs,
and nutritional status of children from low-income households in El Alto, Bolivia. Home visits used culturally adapted
participatory play strategies to promote recommended IFPs. A total of 2014 households with children younger than
12 months at enrollment were randomly assigned to treatment and control groups.

Findings: Caregiver knowledge and IFPs improved by 0·2 standard deviations, as did food expenditures on
recommended foods and dietary diversity. No significant effects were detected on anthropometric indicators or anemia.
Treatment compliance was 88% of households at enrollment and 66% at completion.

Interpretation: Participatory play-based behavioral change strategies are a promising delivery model to improve
recommended IFPs. After 30 months of intervention, we found sustained positive effects on caregiver’s knowledge
and IFPs but no effect on nutritional status. Despite the lack of effect on linear growth and anemia, our results highlight
the relevance of implementing interventions that improve IFPs due to their importance for early development and
prevention of obesity. Other contextual variables, apart from diet, that could be limiting children’s growth potential
in this population need to be identified to design holistic approaches that improve child well-being and human capital.

1. Introduction

It is well documented that stunting early in life affects adult height and cephalopelvic proportions, leading to poor
maternal and neonatal outcomes.1 Stunting is responsible for the inter-generational effects of malnutrition due to its
effects on intrauterine growth and birth weight. 2 Stunting has also been shown to be a risk factor for child survival
and a strong indicator of cumulative deprived environmental conditions that impede the achievement of a child’s
genetic potential for linear growth in several ways.3 This process of becoming stunted early in life (not necessarily
short stature) has severe effects on well-being and economic development due to its association with impaired
development, school achievement, long-term health, and productivity in adulthood .1-6 Therefore, reducing stunting
has been set as a global development goal. Despite favorable global trends, not only do pockets of high prevalence of
stunting persist, but in low and middle-income countries these populations are increasingly accompanied by a rising
prevalence of overweight and obesity, resulting in a double burden of malnutrition.7,8

The implementation of strategies to improve IFPs has been recommended and globally encouraged for several years
to tackle all forms of malnutrition, including stunting and obesity. 9-11 It has been shown that behavioral change
interventions designed with appropriate messages and delivered through interpersonal communication rapidly
improve infant and young children feeding practices.12 However, the evidence on the impact of these interventions on
final growth outcomes is still mixed, from no changes to improvements in growth indicators, depending on the
intervention design and context.13-19 In particular, impacts of education interventions on height-related growth are
reported by very few studies, primarily in Asian countries and with only one study from Latin America, which does
not provide community-based but rather professional nutrition education at health centers in Peru. 20 Effects on
overweight, obesity, or anemia are rarely reported.
Governments in the Latin American region, where stunting, anemia, overweight, and obesity are public health
problems, are making important investments to implement strategies that improve IFPs. Evidence of nutrition
education interventions that effectively improve IFPs and impact height-related growth is lacking for these specific
populations. The objective of this research was to assess the effectiveness of an innovative home-based participatory
play intervention on caregiver’s knowledge, IFPs, and nutritional status of poor infants and young children in Bolivia.

2. Methods

Participants

This study was conducted in the 8th district of the city of El Alto, located 4100m above sea level in the Bolivian
highlands. Households with pregnant women and children under 12 months old were identified using a census
methodology that identified all eligible households in the catchment area. Following baseline data collection, eligible
households were randomly assigned to treatment and control groups (probability of 0.5). The intention-to-treat (ITT)
households were invited to participate in the program, and consenting households (88%) were enrolled. An additional
14 households were recruited after the baseline survey and were randomized following the same procedure.

Procedures

This study builds on the first phase of the Community Child Nutrition (CCN) Project implemented by the Andean
Rural Health Board (CSRA) between 2008 and 2011. Based on evidence from the first phase, CSRA started a renewed
intervention based on formative research that identified existing beliefs, preferences, and practices that represented
potential barriers to adequate child nutrition. 21,22 The redesigned intervention introduced changes in the structure of
the home visits, eliminated growth monitoring activities from home visit protocols, and developed a new approach for
the delivery of the culturally adapted messages.

We evaluated the effectiveness of the second phase of the CCN. The project’s objectives were to improve IFPs,
hygiene, and nutritional status through an innovative behavioral change strategy based on participatory play. The
strategy was delivered to individual households by trained community health workers, most of whom had formal
training as nurses and doctors. The program did not distribute supplements, complementary foods, or provided health
services.

The behavioral change strategy was organized along age-specific curricula called “educational paths,” which
underscored key messages that caregivers should receive, depending on the child’s age at each stage of the intervention
from pregnancy to 24 months of age. During every visit, the educational paths emphasized one message from each of
the following three areas: exclusive breastfeeding or complementary feeding, responsive feeding behavior, and
hygiene (with an emphasis on handwashing). Home visits occurred once or twice per month, depending on the child’s
age (see Supplementary Materials Table A1). The messages were delivered using interpersonal communication and
participatory demonstrations, enriched by an innovative approach of play education, in which program staff conveyed
the nutrition information using interactive play and performing arts such as puppet shows, theater, songs, or poems.
The face-to-face dialogue between staff and family engaged caregivers at a cognitive and emotional level. All activities
were embedded in a defined plot for each visit that reinforced key messages. Children graduated from the program on
their second birthday, regardless of the age at start.

The survey was reviewed and approved by the ethical review board of the National Bioethics Committee in Bolivia.
Informed consent was obtained from the infants’ parents or guardians prior to data collection, and the rights to access
study data were restricted to maintain confidentiality.

Outcomes

We hypothesized that the behavioral change intervention would result in positive deviations in recommended feeding
and hygiene knowledge, and that the adoption of these practices would increase expenditure of recommended foods
at a household level and improve dietary diversity in the child’s diet. These changes would result in improvements of
children’s nutritional status. Given the importance of feeding practices to independently improve nutritional status
and cognitive development, we treated caregiver’s self-reported knowledge and behavior as the intermediate outcomes
for IFPs. Final outcomes are anemia and anthropometric indicators (height-for-age, stunting, weight-for-age, weight-
for-height, overweight, obesity, body-mass index (BMI), and head circumference z-scores). Caregiver’s adoption of
recommended nutrition and hygiene practices was assessed using an aggregate index of responses to 40 knowledge
and 16 practice questions (see Supplementary Materials Tables A2-A5).23 Each index averages the components of
equally weighted questions as:

∑𝐽𝑗=1 𝑥𝑖𝑗
𝐼𝑁𝐷𝐸𝑋𝑖 = ⁄
𝐽

where INDEXi is the index score for household i and xij is the binary response for household i on question j, with xij
= 1 if the caregiver responded according to recommended practice and 0 otherwise. J is the total number of items in
the index. We constructed separate indices for knowledge and behavior related questions, with sub-indices for nutrition
and hygiene and an aggregate score including both. We converted indices to z-scores as follows:

(𝐼𝑁𝐷𝐸𝑋𝑖 − 𝐼𝑁𝐷𝐸𝑋𝐶 )
z-𝐼𝑁𝐷𝐸𝑋𝑖 = ⁄𝑆𝐷
𝐶

where z-INDEXi is the z-score for INDEX in household i, INDEXC is the mean of INDEX in the control group, and
SDC is the standard deviation of INDEX in the control group. As a measure of current nutrition practice, we
additionally drew on a household consumption module and a 24-hour recall of the child’s dietary intake.

Data Collection

Interviews were conducted with the mother or primary caregiver of every eligible child. Questionnaires gathered
information on household sociodemographic and caregiver characteristics. At the child level, we administered
questions on feeding practices and intake of individual food groups in the last 24 hours, using WHO guidelines.24 We
measured children’s anthropometrics and hemoglobin concentration in blood using standardized methods. Weight was
measured using a SECA scale with a precision of ±50 g, height using a wood infantometer, and hemoglobin was
determined from capillary blood samples using a portable photometer (HemoCue®). In addition to the endline and
baseline survey data, we collected administrative data on program implementation, enrollment, participation, and
graduation.

3. Statistical analysis
Treatment effects were estimated using multivariate regression analysis, comparing outcomes in the treatment and
control groups with and without controlling for covariates. Statistical analysis was conducted in Stata® (version 14.0).
We ran the following reduced form model to estimate intent-to-treat effects:

𝑌𝑖 = 𝛼 + 𝛽𝑇𝑖 + ∑𝑛j=1 𝑿𝒊𝒋 + 𝜖𝑖 (1)

where, Yi is the outcome of interest for household or individual i and Ti is a binary variable equal to 1 in the treatment
group and 0 otherwise. β is the average intent-to-treat effect. 𝑿𝒊𝒋 are j household, caregiver or child covariates included
to reduce residual variance in adjusted models. Additional regressions were performed to account for potential
heterogenous treatment effects. We ran the same model separately for the sub-sample of boys and girls, for children
with a height-for-age z-score lower than -1 and lower than -2 at baseline, and for the sub-sample of children whose
mothers completed less than 5 years of education.

The key outcomes examined at endline consisted of a battery of caregiver knowledge and feeding practice indices,
household food expenditure, child dietary diversity, the set of aforementioned anthropometric indicators, and
 hemoglobin levels. We used publicly available guidelines from WHO for the construction of standardized
anthropometric z-score measures.25 Child gender and age were included as covariates to increase precision.

4. Role of the funding source

Baseline data collection and part of the program’s implementation costs were funded with Inter-American
Development Bank (IDB) grant BO-T1181 (ATN/JO-13606-BO), “Improving Child Nutrition Services in Bolivia,” a
technical cooperation project financed through a donation from the IDB’s Japan Special Fund Poverty Reduction
Program (JPO) and executed by the CSRA, in coordination with the Ministry of Health and local public health centers
in El Alto.

Endline data collection was conducted by the Center for Generation of Information and Statistics (CEGIE) at the
Bolivian Private University and funded through the IDB grant BO-T1259 (ATN/OC-15554-BO), “Effectiveness Of
Community Interventions to Reduce Child Malnutrition,” executed by the IDB.

The authors declare no financial interests in the results of the study.

5. Results

Balance and Attrition

The baseline survey was conducted between March and July of 2014. Table 1 presents descriptive statistics for selected
household, caregiver, and child characteristics at baseline. Baseline characteristics were balanced based on treatment
and control assignment.21

Lower Upper
Panel 1: Baseline characteristics Intervention Control Diff bound bound p-value
mean SD mean SD
Caregiver Characteristics N=876 N=876
Caregiver's age in years 27·30 (6·79) 27·48 (6·82) -0·18 -0·821 0·454 0·572
Caregiver's education in years 8·88 (3·78) 9·01 (3·77) -0·13 -0·482 0·226 0·479
Caregiver self-identifies as indigenous = 1 0·83 (0·38) 0·82 (0·39) 0·01 -0·0268 0·0451 0·618
Caregiver married or partnered = 1 0·91 (0·28) 0·91 (0·28) 0·00 -0·0252 0·0275 0·932
Caregiver works 0·305 (0·46) 0·312 (0·46) -0·007 -0·0501 0·0364 0·756

Household Characteristics N=1000 N=1000

Household size 4·797 (1·80) 4·75 (1·80) 0·047 -0·111 0·205 0·559
Number of rooms in the dwelling 1·911 (1·08) 1·941 (1·15) -0·03 -0·128 0·0678 0·548
Electricity connection inside the house = 1 0·998 (0·04) 0·993 (0·08) 0·005* -0·000869 0·0109 0·0949
Bathroom or latrine = 1 0·858 (0·35) 0·837 (0·37) 0·021 -0·0105 0·0525 0·192
Sewerage connection = 1 0·341 (0·47) 0·369 (0·48) -0·028 -0·0700 0·0140 0·191
Phone land line = 1 0·035 (0·18) 0·024 (0·15) 0·011 -0·00384 0·0258 0·146
Mobile phone = 1 0·973 (0·16) 0·972 (0·17) 0·001 -0·0134 0·0154 0·891
Kitchen = 1 0·998 (0·04) 0·992 (0·09) 0·006* -0·000184 0·0122 0·0572
Radio = 1 0·832 (0·37) 0·828 (0·38) 0·004 -0·0290 0·0370 0·812
T·V = 1 0·968 (0·18) 0·958 (0·20) 0·01 -0·00656 0·0266 0·236
Refrigerator = 1 0·181 (0·39) 0·171 (0·38) 0·01 -0·0234 0·0434 0·557
 Automobile = 1 0·237 (0·43) 0·235 (0·42) 0·002 -0·0353 0·0393 0·916
Monthly per-capita income (Bs) 1139·12 (7236·00) 1620·26 (16955·00) -481·13 -1624 662·1 0·409

Child characteristics
n 875 876
Age (Months) 7·962 (6·21) 7·868 (5·77) 0·095 -0·467 0·656 0·741
n 876 876
Gender 0·474 (0·50) 0·508 (0·50) -0·034 -0·0811 0·0126 0·152
n 851 859
Height-for-age z-score (HAZ) -1·03 (1·14) -1·005 (1·10) -0·025 -0·131 0·0816 0·647
n 854 859
Stunted=1 (HAZ<-2) 0·172 (0·38) 0·172 (0·38) 0 -0·0360 0·0356 0·993
n 823 832
Weight-for-age z-score (WAZ) -0·299 (1·02) -0·284 (1·07) -0·014 -0·115 0·0866 0·780
n 823 832
Under-weighted=1 (WAZ<-2) 0·053 (0·23) 0·063 (0·24) -0·009 -0·0316 0·0135 0·432
n 820 830
Weight-for-age z-score (WHZ) 0·511 (1·13) 0·508 (1·18) 0·003 -0·108 0·114 0·961
n 820 830
Wasted=1 (WHZ<-2) 0·027 (0·16) 0·024 (0·15) 0·003 -0·0125 0·0180 0·725
n 823 831
Body-mass index z-score (BMI z-score) 0·428 (1·14) 0·419 (1·17) 0·009 -0·103 0·120 0·876

Panel 2: Endline characteristics

n 776 767
Mother works 0·506 (0·50) 0·449 (0·50) 0·058* 0·00811 0·108 0·0227
n 696 692
Father works 0·955 (0·21) 0·952 (0·21) 0·003 -0·0190 0·0252 0·780
n 741 749
Total household monthly per-capita income
(Bs) 1321·89 (3256·00) 1484·84 (3646·00) -162·95 -514·3 188·4 0·363
Panel 3: Program Participation N=788 N=783
Children received a home visit 0·732 (0·44) 0·061 (0·24) 0·671*** 0·636 0·706 0
Caregiver knows about the home visit
program 0·754 (0·43) 0·097 (0·30) 0·657*** 0·620 0·693 0
Caregiver does not know about the home visit
program 0·246 (0·43) 0·903 (0·30) -0·657*** -0·693 -0·620 0
Table 1: Descriptive Statistics

Note: Standard errors shown in brackets. ***, ** and * indicate statistical significance at the 1, 5 and 10 percent level,
respectively.

At baseline, 21% of the children under 36 months of age were stunted (height-for-age z score <-2 SD), 2% suffered
from acute malnutrition (weight-for-height z score <-3 SD), 3% were overweight, and 1% obese. Of the caregivers,
83% identified themselves as indigenous, mostly Aymara, and 91% were married or lived in a domestic partnership.
Caregivers completed, on average, 9 years of education, and 30% of caregivers worked regularly. The housing and
hygienic conditions in the study area were precarious: 19% lacked access to piped water in their homes, 99% did not
have access to public sanitation, and 88% of households used toilets or pit latrines located outside the house, mostly
without a functioning sink for handwashing.21

The endline survey was conducted between September 2016 and January 2017, approximately 30 months after the
start of recruitment. We tracked all children and caregivers interviewed at baseline. Sample attrition between
baseline and endline was 21% overall and was balanced between treatment and control groups. Attrition was also
balanced in the sub-categories of reject survey (7%), no contact (8%), child deceased (2·3%) and household
migrated outside of La Paz or El Alto (5%). As such, there is no evidence of selective attrition based on treatment
assignment.

Treatment Control
Category (N=1003) (N=1005) Lower Upper p-
Diff
bound bound value
mean SD mean SD
- -
Rejected survey 0·056 (0·23) 0·069 (0·25) 0·013 0·0340 0·00833 0·2350
-
No contact 0·082 (0·27) 0·08 (0·27) 0·002 0·0217 0·0260 0·8699
- -
Child died 0·021 (0·14) 0·023 (0·15) 0·002 0·0148 0·0109 0·7606
Household -
migrated 0·051 (0·22) 0·046 (0·21) 0·005 0·0137 0·0239 0·6030
- -
Total 0·209 0·407 0·217 0·412 0·008 0·0434 0·0283 0·6800

Table 2: Sample attrition

Treatment compliance

We analyzed treatment compliance using administrative records and self-reports. Two control households (out of 1007)
were unintentionally enrolled in the treatment group. At endline, 66% of households completed the program in the
treatment group, graduating the enrolled child at age 24 months. Additionally, 22% of treatment households were
enrolled in the program but failed to graduate, while 12% of households rejected program enrollment.

According to the final survey (Table 1, Panel 3), 73% of households in the treatment group self-reported
participating in the program, while 6% of control households report participating. Even though, randomization
occurred at a household level within the same communities, only 9·7% of control households reported having heard
about the program. Participation in other community nutrition programs was also low in both treatment and control
groups, with fewer than 2·5% of control households reporting participation in alternative programs (Table 1). Figure
1 summarizes the trial profile.
 FIGURE 1: TRIAL PROFILE

2000 eligible households

surveyed at baseline

1605 HH with children

364 HH with identified
pregnant woman
32 HH with both

2014 randomized 14 eligible HH

with no baseline

1007 assigned to 1007 assigned to

nutrition home- control
visits intervention

335 discontinued treatment

216 enrolled but later 2 enrolled
rejected intervention controls
119 rejected enrollment
]

673 graduated HH

791* completed 785* completed

follow-up survey follow-up survey

*Child anthropometric measures were collected for 786 HH in the treatment group and 781 HH in the control group.

Caregiver Knowledge and Practices

Table 3, panel A, presents program impacts on the knowledge, practices, and nutritional indicators described in section
3. Overall effects on feeding practices (16 items) showed a significant effect of 2·5 percentage points, equivalent to
0·19 standard deviations (p<0·01). Effects by sub-indices for complementary feeding, supplement consumption, and
iron-rich food consumption revealed significant program impacts. No effects on responsive feeding were detected.
The overall unadjusted treatment effect on caregiver nutrition knowledge (40 items) represents an increase of 2·3
percentage points, equivalent to approximately 0·17 standard deviations. Sub-indices of exclusive breastfeeding and
complementary feeding were statistically significant.
 Consistent with the positive results on caregiver’s knowledge and practices, we also found positive impacts on
households’ food expenditure on meats, dairy and eggs, and fruits, which were food items promoted by the program
(Table 3, panel B). Expenditures on breads and cereals, oils, tubers and legumes, and fresh vegetables presented a
positive but non-significant difference. Expenditures on sugars, salt and condiments, drinks, and food outside the
home expenditures showed a non-statistically significant negative tendency, also consistent with the program’s
messages that discouraged intake of these foods. The increase in food expenditure translated into increased dietary
diversity for the child (Table 3, panel C), with a 4·1 and 5·4 percentage point increase in the proportion of children
who score 5 and 6 or higher on the minimum dietary diversity scale, respectively.

Anthropometric Measurements and Anemia

Table 3, Panel D presents the observed results on anthropometric indicators. Despite significant effects on feeding
practices and caregiver’s knowledge, we found no significant effects on any of the anthropometric indicators (weight-
for-age, height-for-age, BMI-for-age, weight-for-length z-scores, head circumference, stunting, and wasting) or
anemia. Secondary analysis presented in the Supplementary Materials on heterogeneous effects by gender and age ,
baseline stunting and mother’s education also revealed no detectable impacts of the program. Panel E presents results
on anemia prevalence. Approximately 70% of children were anemic at endline, primarily concentrated in the mild and
moderate categories. No significant effects of the program were detected on severe, moderate, or mild anemia.

Unadjuste Lower Upper p- Adjusted Lower Upper p-

Treatment Control
d effect bound bound value effect bound bound value

mean SD mean SD
A. Feeding Practices and
Knowledge
n 89 783

Standardized knowledge index 0·168 (0·99) 0 (1·00) 0·168*** 0·0686 0·265 0·009 0·140*** 0·0341 0·245 0·009
n 789 783

Standardized practice index 0·203 (1·01) 0 (1·00) 0·203*** 0·107 0·305 0·000 0·211*** 0·105 0·317 0·0009
B. Food Expenditures
(Bolivianos)
n 790 784

Bread and cereals 310·063 (347·00) 296·269 (159·00) 13·794 -12·93 40·51 0·311 13·526 -16·17 43·22 0·372
n 786 782

Meats (offal) 519·118 (646·40) 460·252 (275·40) 58·866** 9·604 108·1 0·019 58·846** 3·548 114·1 0·0370
n 772 776

Oils 46·397 (53·59) 42·864 (29·52) 3·533 -0·778 7·843 0·108 3·178 -1·593 7·949 0·192
n 785 782

Dairy and eggs 280·625 (1317·00) 197·61 (186·40) 83·016* -10·29 176·3 0·0812 93·329* -14·21 200·9 0·088
n 756 754

Tubers and legumes 92·683 (86·51) 89·872 (74·79) 2·812 -5·353 10·98 0·499 2·112 -6·563 10·79 0·633
n 787 781

Fresh vegetables 241·683 (1625·00) 182·274 (576·60) 59·409 -61·58 180·4 0·336 67·113 -72·28 206·5 0·345
n 789 778

Fruit 123·879 (210·70) 107·751 (92·66) 16·127** -0·0383 32·29 0·050 9·050 -5·322 23·42 0·217
n 789 783

Sugars, salt and condiments,

239·895 249·391 -9·495
drinks, food outside the home (181·90) (194·30) -28·11 9·124 0·317 -10·105 -29·82 9·607 0·315
n 792 785

Total Food Expenditures 1838·86 (2541·00) 1616·825 (869·30) 222·035** 34·10 410 0·021 230·165** 16 444·3 0·0352
C. Minimum Dietary
Diversity

n 789 783
Minimum dietary diversity
0·939 0·943 -0·003
(foods score >= 4) (0·24) (0·23) -0·0268 0·0198 0·768 0·003 -0·0225 0·0275 0·842
n 789 783
Minimum dietary diversity
0·835 0·794 0·041**
(foods score >= 5) (0·37) (0·40) 0·00195 0·0785 0·039 0·046** 0·00412 0·0872 0·031
n 789 783
Minimum dietary diversity
0·587 0·533 0·054**
(foods score >= 6) (0·49) (0·50) 0·00395 0·102 0·034 0·043 -0·0097 0·0956 0·110
n 789 783
Minimum dietary diversity
0·253 0·25 0·003
(foods score >= 7) (0·44) (0·43) -0·0404 0·0455 0·908 0·004 -0·0411 0·0496 0·854
D. Anthropometric measures

n 766 747

Weight-for-age z-score -0·338 (0·85) -0·275 (0·85) -0·063 -0·142 0·0311 0·209 -0·051 -0·142 0·0394 0·268
n 776 762

Length/height-for-age z-score -1·341 (0·92) -1·278 (0·93) -0·063 -0·136 0·0499 0·363 -0·036 -0·133 0·0614 0·469
n 766 745

BMI-for-age z-score 0·748 (0·92) 0·767 (0·93) -0·019 -0·122 0·0658 0·558 -0·033 -0·132 0·0658 0·511
n 766 748
Weight-for-length/height z-
0·577 0·608 -0·031
score (0·90) (0·92) -0·133 0·0522 0·393 -0·046 -0·144 0·0517 0·356
n 775 760
Head circumference-for-age z-
-0·116 -0·056 -0·06
score (0·91) (0·90) -0·150 0·0330 0·211 -0·053 -0·151 0·0438 0·281
n 777 763
Moderate or severe chronic
malnutrition (height-for-age) 0·238 0·233 0·005
=1 (0·43) (0·43) -0·0452 0·0407 0·919 0·001 -0·0449 0·0462 0·978
n 766 750
Moderate or severe acute
malnutrition (weight-for- 0·009 0·005 0·004 -
height) =1 (0·10) (0·07) 0·00496 0·0125 0·397 0·003 -0·0068 0·0123 0·574
n 766 745

Overweight or obese =1 0·073 (0·26) 0·077 (0·27) -0·003 -0·0300 0·0239 0·824 0·005 -0·0235 0·0333 0·736
E. Anemia

n 753 738

Severe anemia 0·028 (0·17) 0·026 (0·16) 0·002 -0·0143 0·0186 0·798 0·001 -0·0147 0·0174 0·869
n 753 738

Moderate anemia 0·348 (0·48) 0·359 (0·48) -0·011 -0·0597 0·0375 0·653 -0·017 -0·0683 0·0348 0·524
n 753 738

Mild anemia 0·295 (0·46) 0·308 (0·46) -0·013 -0·0594 0·0339 0·591 -0·015 -0·0649 0·0354 0·564
n 753 738

No anemia 0·329 (0·47) 0·308 (0·46) 0·022 -0·0256 0·0691 0·368 0·030 -0·0205 0·0808 0·243

Table 3: Program effects

6. Discussion

We conducted an effectiveness trial of an innovative behavioral change strategy based on participatory play in the city
of El Alto, Bolivia. The strategy promoted recommended IFPs and hygiene through home visits provided by trained
community health workers. The nutrition and hygiene content was delivered using interpersonal communication
alongside interactive, playful education methods, which had been adapted to the local cultural context based on
formative research. The intervention was implemented according to design, and enrollment compliance reached 88%
at entry, however only 66% of the intent-to-treat sample completed the program.

The implementation of a participatory play-base behavioral change strategy generated significant impacts on improved
caregivers’ knowledge and feeding practices, including complementary feeding, micronutrient supplementation, and
iron-rich food consumption, as well as increased household expenditures on recommended food items and diet
diversification. This is a relevant result in the socio-economic and environmental context of El Alto, due to the
established relationship between improved feeding practices and the reduction of risk of mortality and motor and
language development.14,26 We found no effects on final outcomes of nutritional status (height, weight, or anemia).
The behavior change strategy, was specifically designed to promote adequate feeding practices, including reducing
intake of sugars, fat, and salt. No evidence of unintended effect of the intervention on overweight and obesity (7%
population prevalence at endline) was found. Giving the potential side effect of nutrition interventions focused on
improving feeding practices, especially in areas prone to the “double burden of malnutrition.”, we consider this result
an important outcome.21

The observed positive effects on knowledge and practices confirm that IFPs can be modified through community-
based behavioral change strategies. However, the magnitude of change in practices observed between treatment and
control groups (2·5 percentage points, equivalent to 0·19 standard deviations) might have not been sufficiently large
to affect anthropometric indicators. We also observed improvement in consumption of iron-rich foods. It has been
recently reported that even the smallest indication of inflammation can affect the response to iron supplementation in
children, therefore the effect on anemia could have been mediated by persistent inflammation from chronic and acute
intestinal and respiratory infections. 27 The absence of impact on indicators of nutritional status in this study adds to
the heterogeneity in weight and/or height effects found in the literature. Since countries have committed many
resources to reduce stunting and achieve the Sustainable Development Goals (SDGs) by 2030, this research highlights
the importance of contextual variables and other determinants of malnutrition, apart from diet (e.g. maternal nutrition
and inflammation), that could be driving linear growth in this population.

Four of the potential explanations by Shi (2013) for the heterogeneity on anthropometric outcomes are germane in the
context of this study.15 First, our study population has substantial variation in children’s age at enrollment and follow-
up. Although the intervention was designed to capture children beginning at pregnancy, enrollment was permitted up
to the age of 12 months, which led to variations in the length of exposure and age range during participation. However,
the average length of exposure of 15 months exceeds that of other community-based education interventions that
found impacts on height after 12 months of program duration.28-30 In terms of age range, we did not find evidence of
differential effects when disaggregating the analysis by age groups, although small sample sizes and insufficient
statistical power limit age-disaggregated analysis.

The second potential explanation is related to individual nutritional status at entry. Considering that height-for-age z-
scores between -1 and -2 are more difficult to move upward than the growth of well-nourished children, the 23%
incidence of stunting at entry might have limited the probabilities for success under the given intensity and length of
exposure.
The third aspect refers to the project’s operational strategy and intensity. The educational activities were limited to
individual home visits with intensive face-to-face communication and the use of performing arts and play education
techniques. However, other forms of education, including group meetings for recipe sharing or reinforcement,
community mobilization through influential community or family members, additional in-depth counseling by peers,
laypersons, or professionals, and complementary health services for the management of childhood diseases, were not
provided in this project phase. And above all, the intervention did not include any food supplementation. The
aforementioned are all aspects that differ among nutrition programs around the world and likely play a role in the
achieved behavior change and effects on dietary composition and diversity that eventually translate into growth.

Finally, the broader geographic and socioeconomic context of the intervention is extremely relevant, especially when
considering the first-order dominance of contextual nutrition-sensitive factors such as sanitation, healthcare, and
income in the intervention area. The lack of access to sewerage in nearly all of the households in the intervention area
could promote infectious diseases and chronic problems of the intestinal tract (environmental enteropathy) among
infants, thereby affecting biological growth outcomes. Unfortunately, we do not have the data to examine these
mechanisms in El Alto.

Various policy lessons can be derived from this study. The delivery model we study here, including interactive play,
is a promising way of providing education and counseling to elicit knowledge acquisition and behavior change, and
also offers a novel delivery platform for additional interventions such as supplementation or provision of fortified
complementary foods. Due to the importance of adequate IFPs for early development and prevention of overweight
and obesity, behavior change interventions to improve practices are still valid and need to be implemented, despite
their effect on linear growth and anemia. Under similar conditions, behavioral change strategies may have more impact
on child’s well-being if they are part of an integral approach to improve maternal and child nutrition, increase access
to water and sanitation, reduce poverty, and improve health care access and quality. In other words, behavioral change
strategies can be considered an effective component of health policies, but alone they may not be sufficient to improve
final anthropometric outcomes.

Further research is needed to investigate whether the explicit involvement of influential community leaders or family
members might increase the impact and sustainability of nutrition-related behavior change in the intervention area.
Further research should also examine whether the innovative delivery model, combined with other interventions such
as nutritional supplementation and integrated maternal and child health care, could have effects on final nutrition
outcomes. Furthermore, additional research is needed to compare the cost-effectiveness of the participatory play
method to that of alternative education methods for delivering nutrition messages. Finally, longer term follow-ups are
necessary to measure whether the observed changes in nutrition practice are sustained over time and translate into
growth and other functional outcomes of child’s well-being such as health and cognitive development that would
promote human capital and economic development.

REFERENCES

1 Black RE, Allen LH, Bhutta ZA, Caulfield LE, de Onis M, Ezzati M, Mathers C, Rivera J. Maternal and
child undernutrition: global and regional exposures and health consequences. Lancet 2008; 371:243–60.
2 Ozaltin E, Hill K , Subramanian SV. Association of maternal stature with offspring mortality, underweight,
and stunting in low- to middle-income countries. JAMA 2010; 303:1507–16.
3 Dewey KG, Begum K. Long-term consequences of stunting in early life. Matern Child Nutr 2011; 7(Suppl.
3):5–18.
4 Grantham-McGregor S, Cheung YB, Cueto S, Glewwe P, Richter L, Strupp B. Developmental potential in
the first 5 years for children in developing countries. Lancet 2007; 369:60–70.
5 Victora CG, Adair L, Fall C, Hallal PC, Martorell R, Richter L. et al. Maternal and child undernutrition:
consequences for adult health and human capital. Lancet 2008; 371:340–57.
6 Hoddinott J, Maluccio JA, Behrman JR, Flores R, Martorell R. Effect of a nutrition intervention during
early childhood on economic productivity in Guatemalan adults. Lancet 2008; 371:411–16.
7 De Onis M, Branca F. Childhood stunting: a global perspective. Matern Child Nutr 2016; 12: 12–26.
8 UNICEF, WHO, World Bank Group. Joint Child Malnutrition Estimates. Key findings of the 2017 edition.
9 World Health Organization/UNICEF. Global strategy for infant and young child feeding. Geneva: World
Health Organization, 2003.
10 Bhutta ZA, Ahmed T, Black RE, Cousens S, Dewey K, Giugliani E, Haider BA, Kirkwood B, Morris SS,
Sachdev HP, et al. What works? Interventions for maternal and child undernutrition and survival. Lancet
2008, 371(9610):417–40.
11 Michaelsen KF, Grummer- Strawn L, Bégin F. Emerging issues in complementary feeding: Global aspects
Matern Child Nutr 2017; 13(S2):e12444.
12 Sanghvi T, Seidel R, Baker J, Jimerson A. Using behavior change approaches to improve complementary
feeding practices. Matern Child Nutr 2017;13(S2):e12406.
13 Dewey KG, Adu-Afarwuah S. Systematic review of the efficacy and effectiveness of complementary
feeding interventions in developing countries. Matern Child Nutr 2008; 4(Suppl. 1): 24–85.
14 Imdad A, Yakoob MY, Bhutta ZA. Effect of breastfeeding promotion interventions on breastfeeding rates,
with special focus on developing countries. BMC Public Health 2011; 10(3):S24.
15 Shi L, Zhang J. Recent evidence of the effectiveness of educational interventions for improving
complementary feeding practices in developing countries. J Trop Pediatr 2011; 57(2):91–8.
16 Lassi ZS, Das JK, Guleshehwar Z, Imdad A, Bhutta Z. Impact of education and provision of
complementary feeding on growth and morbidity in children less than years of in developing countries: a
systemic review. BMC Public Health 2013; 13(Suppl. 3): S13.
17 Sunguya BF, Poudel KC, Mlunde LB, Shakya P, Urassa DP, Jimba M, Yauoka J. Effectiveness of nutrition
training of health workers toward improving caregivers’ feeding practices for children aged six months to
two years: a systematic review. Nutrition Journal 2013; 12:66.
18 Fabrizio CS, van Liere M, Pelto G. Identifying determinants of effective complementary feeding behavior
change interventions in developing countries. Matern Child Nutr 2014; 10:575–92.
19 Krasevec J, An X, Kumapley R, Bégin F, Frongillo EA. Diet quality and risk of stunting among infants and
young children in low- and middle-income countries. Matern Child Nutr 2017;13(S2):e12430
20 Penny ME, Creed-Kanashiro HM, Robert RC, Narro MR, Caulfield LE, Black RE. Effectiveness of an
educational intervention delivered through the health services to improve nutrition in young children: a
cluster-randomized controlled trial. Lancet. 2005; 365(9474):1863–72.
21 Gertner G, Johannsen J, Martinez S. Situación de salud, nutrición y saneamiento entre los niños menores de
12 meses en el Distrito 8 de El Alto: Resultados de encuesta de línea de base del Programa de
Mejoramiento Nutricional en El Alto, Bolivia fase II. IDB technical Note No. IDB-TN-1118. Washington,
DC: Inter-American Development Bank.
22 Gertner G, Johannsen J, Martinez S. Effects of Nutrition Promotion on Child Growth in El Alto, Bolivia:
Results from a Geographic Discontinuity Design.” Economia Journal of the Latin American and Caribbean
Economic Association. Vol. 17 N1. 2016.
23 Kling J, Liebman J B, Katz L F. Experimental analysis of neighborhood effects. Econometrica 2007; 75(1):
83-119.
24 World Health Organization, UNICEF, USAID, AED, UCDAVIS, IFPRI. Indicators for assessing infant
and young child feeding practices. Geneva: World Health Organization, 2010.
25 World Health Organization. WHO Anthro (version 3.2.2, January 2011) and macros. Available at:
http://www.who.int/childgrowth/software/en/ (accessed Oct 14, 2016).
26 Frongillo EA, Ngduyen PH, Saha KK, Sanghvi T, Afsana K, Haque R, Baker J, Ruel MT, Rawat R, Menon
P. Large-Scale Behavior-Change Initiative for Infant and Young Child Feeding Advanced Language and
Motor Development in a Cluster-Randomized Program Evaluation in Bangladesh. J Nutr 2017; 147(2):256-
63.
27 Prentice AM. The HIGH Trials in rural Gambia: design, initial results and implications. Oral Presentation.
IUNS Congress. Buenos Aires, Argentina. 2017.
28 Bhandari N, Mazumder S, Bahl R, Martines J, Black RE, Bhan MK. Infant Feeding Study Group. An
educational approach to promote appropriate complementary feeding practices and physical growth in
infants and young children in rural Haryana, India. J Nutr 2004; 134(9): 2342-8.
29 Salehi M, Kimiagar SM, Shahbazi M, Mehrabi Y, Kolahi A. Assessing the impact of nutrition education on
growth indices of Iranian nomadic children: an application of a modified beliefs, attitudes, subjective
norms and enabling-factors model. Br J Nutr 2004; 91(05): 779-87.
30 Guldan GS, Fan HC, Ma X, Ni ZZ, Xiang X, and Tang MZ. Culturally appropriate nutrition education
improves infant feeding and growth in rural Sichuan, China. J Nutr 2004; 130 (5):1204-11.