The Haitian National Nutrition Policy identifies the promotion of optimal complementary feeding (CF) practices as a priority action to prevent childhood malnutrition. We analysed data from the nationally representative 2005-2006 Haiti Demographic Health Survey using the World Health Organization 2008 infant and young child feeding indicators to describe feeding practices among children aged 6-23 months and thus inform policy and programme planning. Multivariate regression analyses were used to identify the determinants of CF practices and to examine their association with child growth outcomes. Overall, 87.3% of 6-8-month-olds received soft, solid or semi-solid foods in the previous 24 h. Minimum dietary diversity (MDD), minimum meal frequency (MMF) and minimum acceptable diet (MAD) were achieved in 29.2%, 45.3% and 17.1% of children aged 6-23 months, respectively. Non-breastfed children were more likely to achieve MDD than breastfed children of the same age (37.3% vs. 25.8%; P < 0.001). The proportion of children achieving MMF varied significantly by age (P < 0.001). Children with overweight mothers were more likely to achieve MDD, MMF and MAD [odds ratio (OR) 2.08, P = 0.012; OR 1.81, P = 0.02; and OR 2.4, P = 0.01, respectively] than children of normal weight mothers. Odds of achieving MDD and MMF increased with household wealth. Among mothers with secondary or more education, achieving MDD or MAD was significantly associated with lower mean weight-for-age z-score and height-for-age z-score (P-value <0.05 for infants and young child feeding indicator × maternal education interaction). CF practices were mostly inadequate and contributed to growth faltering among Haitian children 6-23 months old.

Background : Water represents the core of food-energy nexus and is vital for human survival. In developing countries, contaminated water and lack of basic water services undermine efforts to improve nutritional status and related health issues. In the rural areas of Central Africa, a majority of the population lacks access to improved water sources and has to devote considerable efforts to obtain water. Objectives : Using the following definition of water insecurity, i.e. it exists when access to adequate amount of safe and clean water does not occur all the times for the entirety of household members to lead a healthy and active life, the study aimed to develop and test a household-level experiential water insecurity scale for rural households in Central Africa. Methods : The research was conducted in three phases: 1) the formative data collection; 2) the scale development; and, 3) the scale testing. In the third Phase, the scale was tested with 250 women who were water managing person of their households. Statistical analysis included items reduction, reliability, as well as criterion and construct validity assessment. The testing led to a final scale of 17 statements (WATINE-17), covering three domains of water insecurity: 1) psychosocial distress; 2) quantity; 3) quality of water. Results : The scale showed an excellent reliability (Cronbach’s alpha = 0.92) and was significantly associated with lower frequency of water intake among women (p = 0.007, concurrent validity). In assessing WATINE-17’s predictive validity, it was found that water insecurity was positively related to food insecurity (p < 0.001) and the level of water insecurity was the highest among severely food insecure households [F (3, 246) = 22.469, p < 0.001]. Conclusion : The WATINE-17 is able to capture key elements of water insecurity and can be used to monitor and evaluate SDG# 6 and water-related programs, such as WASH, in Central Africa.

Haiti's national nutrition policy prioritises breastfeeding, but limited data are available to inform strategy. We examined national trends in early initiation of breastfeeding (ErIBF) and exclusive breastfeeding (EBF) over a 10-year period using data from three Haitian Demographic and Health Surveys (1994-1995, 2000 and 2005-2006). We used multivariate regression methods to identify determinants of ErIBF and EBF in the 2005-2006 data set and to examine relationships to growth. There was no change in ErIBF across surveys [1994-1995: 36.6%, 95% confidence interval (CI) 29.9-43.9; 2000: 49.4%, 95% CI 44.1-54.8; 2005-2006: 43.8%, 95% CI 40.5-47.1]. EBF among 0-5-month-olds increased sharply (1994-18995: 1.1%, 95% CI 0.4-3.2; 2000: 22.4%, 95% CI 16.5-29.5; 2005-2006: 41.2%, 95% CI 35.4-47.2). The proportion of breastfeeding children 0-5 months who received soft, solid or semi-solid foods decreased (1994-1995: 68.5%, 95% CI 57.3-77.9; 2000: 46.3%, 95% CI 39.3-53.4; 2005-2006: 30.9%, 95% CI 25.9-36.5). Child age at time of survey [odds ratio (OR) 1.73; P = 0.027], lower maternal education (OR = 2.14, P = 0.004) and residence in the Artibonite Department (OR 0.31; P = 0.001) were associated with ErIBF among children 0-23 months. Age group and department were significant predictors of EBF among children 0-5 months. ErIBF was associated with higher weight-for-age z-scores [effect size (ES) 0.22; P = 0.033] and height-for-age z-scores (ES 0.20; P = 0.044). There was no statistically significant relationship between EBF and growth. The 10-year ErIBF and EBF trends in Haiti echo global and regional trends. ErIBF and EBF are related practices but with different determinants in the Haitian context. These differences have implications for intervention delivery.

Objectives We modeled the potential impacts of bouillon fortification with different levels of vitamin A, folic acid, vitamin B12, iron, and zinc on dietary micronutrient adequacy to inform multi-stakeholder discussions around bouillon fortification programs. Methods We used individual dietary intake data in Cameroon from women of reproductive age (WRA) and children 1–5 y (n = 902 and 872), and household (HH) survey data in Cameroon (n = 11,384 HH), Ghana (n = 11,870 HH), and Haiti (n = 4,951 HH) to estimate micronutrient (MN) intake. The Adult Male Equivalent method was applied to estimate “apparent intake” of WRA, children, and men from HH surveys. We examined intake of bouillon and calculated prevalence of inadequate (below the estimated average requirement) and high (above the tolerable upper intake level, UL) micronutrient intake. Analyses included the contributions of mandatory fortification of oil or wheat flour at estimated current micronutrient levels. We simulated the impacts of bouillon fortification with varying levels of vitamin A, folic acid, vitamin B12, iron, and zinc on inadequate and high intakes of each nutrient. Results Bouillon was commonly consumed in all countries, with any reported consumption ranging from 67–81% in Ghana to over 90% in Cameroon and Haiti. Median (apparent) bouillon consumption ranged from 1.6–2.1 g/d for women, 0.7–1.0 g/d for children, and 1.8–2.2 g/d for men. Bouillon fortification with vitamins was predicted to reduce dietary inadequacy (120 μg/g vitamin A: 15–33 percentage points, pp, depending on the country and target group; 80 μg/g folate: 11–33 pp; 1.2 μg/g B12: 12–67 pp) with minimal risk of high intake. In contrast, predicted effects on dietary iron inadequacy were modest (5–12 pp reduction at 5 mg iron/g, assuming 2% absorption). Simulated zinc fortification showed reductions in inadequate absorbable zinc intake (14–42 pp at 3 mg/g), but children's intakes commonly exceeded the UL. Conclusions Modeling suggests that bouillon fortification could reduce inadequate MN intakes in these countries. Further work is needed to identify fortification levels that will meet criteria for nutritional benefits, technical feasibility, and cost-effectiveness. Funding Sources This analysis was supported by a grant to UC Davis from Helen Keller International.

To gain further understanding of the interlinkages between poor water access, household food insecurity, and undernutrition among children, this study used a cross-sectional design with 474 female caretakers of children suffering from moderate acute malnutrition (MAM) to explore the relationship between limited access to water and diarrheal diseases among children, aged &lt;5 years, experiencing MAM. The mean age of the caretakers was 28.50±6.88 years and that of their MAM children (sex ratio=0.7) was 17.79±9.59 months. The participants reported spending an average of 19.29±15.69 min for one trip to fetch water. A negative correlation was found between mean time spent fetching drinking water and hygiene and handwashing score (r=−0.141, p=0.003). Furthermore, the more severe the food insecurity status of a household, the farther the family member likely had to go to fetch for drinking water [F(2, 444)=8.64, p≤0.001]. Results from binary logistic regression showed that children from households practicing open defecation (p=0.008) and/or having inadequate hygiene practices (p=0.004) had increased odds of developing diarrhea. Therefore, ameliorating water access in households with MAM children could contribute to improvements in hygiene and sanitation attitudes with a subsequent increase in the effectiveness of nutrition interventions aiming at reducing acute malnutrition among children.

Objectives • to explore how and through what multi-level pathways the Ebola outbreak impacted the nutrition sector in Sierra Leone • to investigate the barriers and facilitating factors to implementing effective response strategies during the nutrition response • to develop an improved preparedness and nutrition response framework for consideration during future outbreaks of this nature. Methods This qualitative study had an iterative and emergent design. In-depth interviews (n = 42) were conducted over two phases by purposively sampling both key informants (n = 21; government stakeholders, management staff from United Nations agencies and non-governmental organizations (NGO), and informants (n = 21; community members, Ebola survivors, front-line workers) until data saturation was reached. Multiple analysts worked collaboratively in a team-based coding approach to identify key themes and sub-themes using Dedoose software. Findings are presented as both salient quotations and tables/figures to illustrate the results. Results The Ebola outbreak and related response strategies, especially movement restriction policies, disrupted nearly every aspect of the food value-chain in Sierra Leone. Through production, storage and processing, distribution, transport and trade, and retailing, salient themes emerged across interviews with Government, United Nations, and NGO stakeholders, as well as community-level participants about the serious effects of the outbreak on food and nutrition. Data suggest that the effects of the outbreak had an aggregate negative effect on key pillars of food security as well as infant and young child feeding practices. Food-based response efforts were highly accepted, although sharing and selling of food assistance was reported by front-line workers and community members alike. Conclusions Infectious diseases such as Ebola have far-reaching effects that are not just directly bio-medical in nature but also indirectly impacting health through the entire food value-chain from agriculture agricultural disruption to individual nutritional status. A food value-chain approach therefore may offer a viable framework from which to position nutrition preparedness and response efforts for infectious disease outbreaks in other similar food insecure settings. Funding Sources UNICEF West and Central Africa Regional Bureau. Supporting Tables, Images and/or Graphs

Policymakers are committed to improving nutritional status and to saving lives. Some micronutrient intervention programs (MIPs) can do both, but not to the same degrees. We apply the Micronutrient Intervention Modeling tool to compare sets of MIPs for (1) achieving dietary adequacy separately for zinc, vitamin A (VA), and folate for children and women of reproductive age (WRA), and (2) saving children's lives via combinations of MIPs. We used 24‐h dietary recall data from Cameroon to estimate usual intake distributions of zinc and VA for children 6–59 months and of folate for WRA. We simulated the effects on dietary inadequacy and lives saved of four fortified foods and two VA supplementation (VAS) platforms. We estimated program costs over 10 years. To promote micronutrient‐specific dietary adequacy, the economic optimization model (EOM) selected zinc‐ and folic acid–fortified wheat flour, VA‐fortified edible oils, and bouillon cubes, and VAS via Child Health Days in the North macroregion. A different set of cost‐effective MIPs emerged for reducing child mortality, shifting away from VA and toward more zinc for children and more folic acid for WRA. The EOM identified more efficient sets of MIPs than the business‐as‐usual MIPs, especially among programs aiming to save lives.

A variety of nutrition interventions are needed to meet national and global goals for women and children, and scarce resources necessitate integration of those activities. Haiti's national nutrition strategy includes 3 priority intervention areas: 1) promotion of age‐appropriate infant and young child feeding (IYCF) practices 2) prevention of micronutrient deficiencies (PMD) in young children, adolescent girls and pregnant women and 3) management of severe acute malnutrition (SAM) in children under 5. Policy makers need to identify program delivery models that effectively integrate these areas at the community level. To address the question of integration, we mapped the program impact pathways for 3 large‐scale nutrition programs serving rural Haitian communities. Two programs were managed by NGOs and one by the public sector. For each program, we assessed how activities related to IYCF, PMD, and SAM were integrated at the service delivery level. Data was collected through document review and semi‐structured interviews with program staff and beneficiaries. Analyses and findings reveal ways that various community‐based nutrition activities can be most efficient and synergistic. Research support: UNICEF Haiti