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Ghana Health Service. Charles Sagoe-Moses is affiliated with was selected as the African MGRS site. Twenty-five hos- the Regional Health Administration, ...

)MPLEMENTATIONOFTHE7(/-ULTICENTRE'ROWTH 2EFERENCE3TUDYIN'HANA

!NNA,ARTEY 7ILLIAM"/WUSU )SABELLA3AGOE -OSES 6ERONICA'OMEZ AND #HARLES3AGOE -OSES FORTHE7(/-ULTICENTRE'ROWTH2EFERENCE3TUDY'ROUP !BSTRACT

)NTRODUCTION

4HE7ORLD (EALTH /RGANIZATION 7(/ -ULTICENTRE 'ROWTH 2EFERENCE 3TUDY -'23 !FRICAN SITE WAS !CCRA 'HANA )TS SAMPLE WAS DRAWN FROM  AFFLUENT RESIDENTIALAREASWHEREEARLIERRESEARCHHADDEMONSTRATED THEPRESENCEOFACHILDSUBPOPULATIONWITHUNCONSTRAINED GROWTH 4HIS SUBPOPULATION COULD BE IDENTIFIED ON THE BASISOFTHEFATHERSEDUCATIONANDHOUSEHOLDINCOME4HE SUBJECTSFORTHELONGITUDINALSTUDYWEREENROLLEDFROM HOSPITALSANDDELIVERYFACILITIESTHATACCOUNTEDFOR OFTHESTUDYAREASBIRTHS4HECROSS SECTIONALSAMPLEWAS RECRUITEDATDAY CARECENTERSUSEDBYMORETHAN OFTHETARGETEDSUBPOPULATION0UBLICRELATIONSEFFORTSWERE MOUNTED TO PROMOTE THE STUDY IN THE COMMUNITY4HE LARGENUMBEROFFACILITIESINVOLVEDINTHELONGITUDINALAND CROSS SECTIONALCOMPONENTS THERELATIVELYLARGEGEOGRAPHIC AREACOVEREDBYTHESTUDY ANDTHEDIFFICULTIESOFWORKING IN A DENSELY POPULATED URBAN AREA PRESENTED SPECIAL CHALLENGES #ONVERSELY THE HIGH RATES OF BREASTFEEDING AND GENERAL SUPPORT FOR THIS PRACTICE GREATLY FACILITATED THEIMPLEMENTATIONOFTHE-'23PROTOCOL

4HE7ORLD(EALTH/RGANIZATION7(/ -ULTICENTRE 'ROWTH 2EFERENCE 3TUDY -'23 !FRICAN SITE WAS !CCRA 'HANA'HANAISINTHE7EST!FRICASUBREGION HASAPOPULATIONOFMILLION;= ANDLIESKM NORTHOFTHEEQUATOR)THASTWOMAINSEASONSTHEWET SEASON WHICHPEAKSFROM!PRILTO*UNE ANDTHEDRY SEASONBETWEEN.OVEMBERAND-ARCH )NCLUSION OF THE 'HANAIAN SITE WAS DEPENDENT ON IDENTIFYINGASUBPOPULATIONOFCHILDRENWITHNOSOCIO ECONOMICCONSTRAINTSONGROWTH'OVERNMENTPROPERTY VALUATIONSWEREUSEDTOIDENTIFYCOMMUNITIESINTHE MOST AFFLUENT AREAS OF!CCRA THE!IRPORT 2ESIDENTIAL AREA !TOMIC !DENTA #ANTOMENTS $ANSOMAN $ZOR WULU %AST,EGON,EGON -ANETTE3AKUMONO,ASHIBI 2OMAN2IDGE AND4EMA4HEYWERESURVEYEDTOASSESS THEFEASIBILITYOFCONDUCTINGTHE-'23;=(OUSEHOLDS WITH CHILDREN AGED BETWEEN  AND  MONTHS WERE IDENTIFIED INFORMATION ON HOUSEHOLD DEMOGRAPHIC ANDSOCIOECONOMICCHARACTERISTICSWASCOLLECTEDAND ANTHROPOMETRIC MEASUREMENTS OF THE CHILDREN THEIR MOTHERSANDGRANDMOTHERSWEREOBTAINED4HISINFOR MATION WAS USED TO IDENTIFY SOCIOECONOMIC FACTORS ASSOCIATEDWITHUNCONSTRAINEDGROWTHINEARLYCHILD HOOD)NFORMATIONWASALSOCOLLECTEDONHOSPITALSAND OTHERDELIVERYFACILITIESUSEDBYWOMENINTHESELECTED RESIDENTIALAREAS 4HESURVEYIDENTIFIEDTHESOCIOECONOMICCHARACTER ISTICSASSOCIATEDWITHUNCONSTRAINEDGROWTHOFCHILDREN FROMAFFLUENTFAMILIESTOBEHIGHLEVELOFEDUCATIONTER TIARY OFTHEFATHERANDHOUSEHOLDINCOME;=(AVING METTHECRITERIAREQUIREDOFPARTICIPATINGSITES;= !CCRA WASSELECTEDASTHE!FRICAN-'23SITE4WENTY FIVEHOS PITALSANDOTHERDELIVERYFACILITIESWEREIDENTIFIEDTHAT ACCOUNTEDFOROFBIRTHSINTHETARGETEDSUBPOPULA TION4HESUBJECTSWERERECRUITEDFROMTHOSESITES4HE OBJECTIVEOFTHISPAPERISTOPROVIDEANOVERVIEWOFTHE IMPLEMENTATIONOFTHE-'23ATTHE'HANAIANSITE

+EY WORDS !NTHROPOMETRY BREASTFEEDING CHILD HEALTH CHILDNUTRITION 'HANA GROWTH GROWTHMONI TORING GROWTHREFERENCES INFANTFEEDINGPRACTICES

!NNA,ARTEYAND7ILLIAM"/WUSUAREAFFILIATEDWITHTHE $EPARTMENT OF .UTRITION AND &OOD 3CIENCE 5NIVERSITY OF 'HANA ,EGON )SABELLA 3AGOE -OSES AND6ERONICA 'OMEZ AREAFFILIATEDWITHTHE2EPRODUCTIVEAND#HILD(EALTH5NIT 'HANA(EALTH3ERVICE#HARLES3AGOE -OSESISAFFILIATEDWITH THE2EGIONAL(EALTH!DMINISTRATION 'REATER!CCRA2EGION 'HANA(EALTH3ERVICE 0LEASE DIRECT QUERIES TO -ERCEDES DE /NIS 3TUDY #OOR DINATOR $EPARTMENT OF .UTRITION 7ORLD (EALTH /RGANI ZATION  !VENUE !PPIA  'ENEVA  3WITZERLAND 4ELEPHONE     FAX     E MAIL DEONISM WHOINT -EMBERS OF THE 7(/ -ULTICENTRE 'ROWTH 2EFERENCE 3TUDY'ROUPAND!CKNOWLEDGMENTSARELISTEDATTHEENDOF THEFIRSTPAPERINTHISSUPPLEMENTPP3n3 

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4HE -'23 PROTOCOL IS DESCRIBED IN DETAIL ELSEWHERE IN THIS SUPPLEMENT ;= 4HE TIMELINE FOR ITS IMPLE MENTATION IN !CCRA IS SUMMARIZED IN FIGURE  4HE PREPARATORYPHASELASTEDFROM*UNETO/CTOBER DATACOLLECTIONFORTHELONGITUDINALCOMPONENTOFTHE STUDYWASINITIATEDIN$ECEMBERANDCOMPLETEDIN $ECEMBER4HECROSS SECTIONALCOMPONENTLASTED FROM.OVEMBERTO-AY 4HEPRINCIPALINVESTIGATORSANDORONEOFTHEOTHER MEMBERSOFTHERESEARCHTEAMVISITEDEACHOFTHE HOSPITALSANDOTHERDELIVERYSITESTODISCUSSTHEAIMS ANDPROCEDURESOFTHESTUDY,ETTERSWEREALSOSENTTO EACH HOSPITAL FORMALLY SEEKING PERMISSION TO RECRUIT INFANTS!LLGAVEWRITTENCONSENT EXCEPTFORONEFACILITY WHOSEDIRECTORGAVEORALCONSENT%ACHFACILITYIDENTI FIEDONEORTWOMATERNITYWARDNURSESTOSERVEASCON TACTSBETWEENTHEPROJECTANDTHEDELIVERYWARD4HESE SENIOR MATERNITY WARD NURSES IN CHARGE OF DELIVERIES ENABLEDTHEPROJECTTOIDENTIFYALLDELIVERIESWITHINTHE REQUIREDHOURSAFTERBIRTH )NSTITUTIONAL APPROVALS WERE OBTAINED FROM THE 5NIVERSITY OF 'HANA -EDICAL 3CHOOL %THICAL 2EVIEW #OMMITTEE 3TUDYTEAMS

4HESITEHADFOURSTUDYTEAMSCOORDINATION SCREENING LACTATIONSUPPORT ANDFOLLOW UP4HEPOSITIONSFORALL FIELDRESEARCHASSISTANTSWEREADVERTISEDINTHE5NIVER SITYOF'HANA1UALIFIEDAPPLICANTSWEREINTERVIEWED ANDRECRUITEDBASEDONTHEIRMOTIVATION COMMUNICA TIONSKILLS DEDICATIONTOWORK ANDABILITYTOWORKIN ATEAM 4HECOORDINATIONTEAMCONSISTEDOFTHETWOPRINCIPAL INVESTIGATORS LACTATION SUPERVISORS A QUALITY CONTROL

MANAGER A DATA MANAGER A PROJECT SECRETARY AND A PROJECTADVISER4HECOORDINATIONTEAMWASRESPONSIBLE FORTHEOVERALLADMINISTRATIONOFTHESTUDY 4HESCREENINGTEAMWASMADEUPOFSIXMEMBERS ALL WITHUNDERGRADUATEUNIVERSITYDEGREESINNUTRITIONOR NURSING4HISTEAMWASHOSPITALBASEDANDWASRESPON SIBLEFORTHEIDENTIFICATIONANDSCREENINGOFNEWBORNS FORELIGIBILITYANDFOROBTAININGINITIALANTHROPOMETRIC MEASUREMENTSOFENROLLEDSUBJECTS4HESCREENINGTEAM WORKEDFIVEDAYSAWEEK-ONDAYTO&RIDAY  4HE LACTATION TEAM WAS MADE UP OF  SENIOR OR PRINCIPAL NURSING OFFICERS WORKING WITH THE 'HANA (EALTH 3ERVICE %ACH HAD SUCCESSFULLY COMPLETED THE 7(/LACTATIONMANAGEMENTANDBREASTFEEDINGCOUN SELINGCOURSE;=BEFORETHE-'23WASIMPLEMENTEDIN 'HANA%ACHALSOUSEDTHEKNOWLEDGEANDSKILLSGAINED THROUGHTHATTRAININGINTHEIRUSUALEMPLOYMENT4HE LACTATIONCOUNSELORSASSISTEDNEWLYDELIVEREDMOTHERS TO INITIATE BREASTFEEDING SUCCESSFULLY IN THE HOSPITAL ENCOURAGEDMOTHERSTOCOMPLYWITHTHEFEEDINGREC OMMENDATIONS OF THE STUDY AND HELPED THEM SOLVE ANY BREASTFEEDING PROBLEMS THAT THEY EXPERIENCED 4HEY ADMINISTERED THE BREASTFEEDING QUESTIONNAIRES AND OBTAINED INFANT WEIGHTS AT THE FIRST HOME VISIT 4HELACTATIONCOUNSELORSWORKEDPART TIMEHOWEVER THEMOTHERSCOULDCALLTHEIRASSIGNEDLACTATIONCOUN SELORSORTHELACTATIONTEAMSUPERVISORHOURSADAY SEVENDAYSAWEEK 4HEFOLLOW UPTEAMWASMADEUPOFSIXINDIVIDU ALS ALL WITH UNDERGRADUATE DEGREES IN NUTRITION 4HE TEAMWASRESPONSIBLEFORHOMEVISITS4HEYADMINIS TEREDBASELINEANDFOLLOW UPQUESTIONNAIRESANDTOOK ANTHROPOMETRICMEASUREMENTSOFCHILDRENANDPARENTS 4HETEAMNORMALLYWORKEDFROM-ONDAYTO3ATURDAY 3OMEHOMEVISITSWERESCHEDULEDON3UNDAYSTOENSURE THEFATHERSAVAILABILITY4HESAMEFOLLOW UPINTERVIEW ERSPARTICIPATEDINTHELONGITUDINALANDCROSS SECTIONAL COMPONENTSOFTHESTUDY&IGURESHOWSTHECOORDINA TIONOFSTUDYTEAMS

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! ONE DAY WORKSHOP WAS HELD FOR ALL NURSES SERVING AS PROJECT CONTACTS TO REVIEW THE PROJECTS GOALS AND PROCEDURESANDTHEIRRESPECTIVEROLESINITSSUCCESSFUL IMPLEMENTATION4HEFIELDRESEARCHASSISTANTSTRAINING INCLUDEDAREVIEWOFTHEBACKGROUNDANDOBJECTIVESOF THE-'23 THEADMINISTRATIONOFQUESTIONNAIRES AND THE STANDARDIZED USE OF STUDY FORMS AND INTERVIEWER GUIDES0ARTICULARATTENTIONWASGIVENTOTHEESTIMATION OFGESTATIONALAGE WHICHWASCALCULATEDONTHEBASIS OF ULTRASOUND OR ESTIMATED FROM THE LAST MENSTRUAL PERIOD 4HE INTERVIEWERS WERE TRAINED IN THE USE OF hGESTOGRAMSv ;= USING THE LAST MENSTRUAL PERIOD AS THE BASE FOR THE CALCULATION &OLLOW UP INTERVIEWERS ALSO CONDUCTED ROLE PLAYING SESSIONS AT PARTICIPATING MATERNALANDCHILDHEALTHCLINICSTOHONEINTERVIEWING SKILLS!COUNSELINGEXPERTPROVIDEDTRAININGININTER VIEWINGTECHNIQUESANDREVIEWEDCULTURALLYACCEPTABLE BEHAVIORSTOBEOBSERVEDDURINGHOMEVISITS !NTHROPOMETRIC TRAINING AND STANDARDIZATION FOL LOWEDTHE-'23PROCEDURES;=0RACTICESESSIONSON THEPROPERHANDLINGOFNEWBORNSWERECONDUCTEDAT ONE OF THE PARTICIPATING HOSPITALS AND THE SCREENING TEAM RECEIVED PRACTICAL TRAINING IN OBTAINING MEAS UREMENTSONNEWBORNS4HEFOLLOW UPTEAMPRACTICED ANTHROPOMETRICMEASUREMENTTECHNIQUESONCHILDREN ATTENDINGGROWTHMONITORINGANDIMMUNIZATIONCLIN ICS"EFORETHESTARTOFDATACOLLECTION THEANTHROPOM ETRY TEAMS PARTICIPATED IN A FORMAL STANDARDIZATION SESSION INVOLVING ONE OF THE TWO 7(/ DESIGNATED LEADANTHROPOMETRISTS ASDESCRIBEDELSEWHEREINTHIS SUPPLEMENT;=4EAMMEMBERSWHOSEMEASUREMENTS WERE CHARACTERIZED BY LOW ACCURACY ANDOR PRECISION WEREGIVENCORRECTIVETRAINING!FTERTHISINITIALSTAND ARDIZATIONWITHTHE7(/ DESIGNATEDLEADANTHROPOM ETRIST SIXSCREENINGANDSIXFOLLOW UPINTERVIEWERSWERE SELECTEDFORTHEINITIALTEAMS4WOADEQUATELYTRAINED INTERVIEWERSWERESELECTEDASBACKUPS4HEANTHROPOM ETRYSTANDARDIZATIONSESSIONSWEREREPEATEDEVERYTWO MONTHS SEPARATELY FOR THE SCREENING AND FOLLOW UP TEAMS WITHTHEPARTICIPATIONONCEAYEAROFTHE7(/ DESIGNATEDLEADANTHROPOMETRIST 3ELECTEDINTERVIEWERSWEREALSOTRAINEDBYSTAFFFROM THE -'23 #OORDINATING #ENTRE IN 'ENEVA TO ASSESS THEACHIEVEMENTOFTHESIXMOTORDEVELOPMENTALMILE STONES FOLLOWINGTHE-'23PROTOCOL;= 4HETRAININGOFTHELACTATIONSUPPORTTEAMMEMBERS FORTHESTUDYFOCUSEDONPROVIDINGSUPPORTTOMOTH ERS IN FULFILLING THE -'23 FEEDING REQUIREMENTS ;= ADMINISTERING THE BREASTFEEDING QUESTIONNAIRES AND MEASURINGMOTHERSANDBABIESWEIGHTSATTHEWEEK VISIT 4HREEWEEKSBEFOREDATACOLLECTIONWASINITIATED A TWO WEEKPILOTSTUDYWASCONDUCTEDTOTESTTHELOGISTICS OFTHESITE4HEHOSPITALSANDOTHERDELIVERYFACILITIES FROMWHICHSUBJECTSWOULDBERECRUITEDWEREGROUPED

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INTOTHREECLUSTERSOFNINE NINE ANDSEVEN/NEPAIROF SCREENERSWASASSIGNEDTOEACHCLUSTER4HEPILOTSTUDY DEMONSTRATED THAT !CCRAS HEAVY TRAFFIC WOULD BE A MAJOR CHALLENGE /N THE BASIS OF THESE EXPERIENCES THE SCREENING TEAMS WERE REQUIRED TO START THEIR DAY NOLATERTHANAM ANDTHECLUSTERINGOFHOSPITALSAND OTHERDELIVERYFACILITIESWASREORGANIZEDTOAVOIDHEAVY TRAFFICAREAS !DAPTATIONOFSTUDYMATERIALSANDPROCEDURES

4HEGENERIC-ANUALOF/PERATIONSWASADAPTEDTOTHE CIRCUMSTANCES OF THE SITE WITH THE ASSISTANCE OF THE 7(/ #OORDINATING #ENTRE AS DESCRIBED ELSEWHERE INTHISSUPPLEMENT;=4HEELIGIBILITYCRITERIASPECIFIC TO THE 'HANA SITE ARE SHOWN IN TABLE  4HIS SITE DID NOT USE NONINTENTION TO BREASTFEED AS AN EXCLUSION CRITERION SINCE BREASTFEEDING IS NEARLY UNIVERSAL IN 'HANA!TOURSITEITWASNOTNECESSARYTOTRANSLATETHE STUDYQUESTIONNAIRESINTOLOCALLANGUAGES4HEMOTHERS ENROLLEDINTHESTUDYALLSPOKE%NGLISHFLUENTLY ASWOULD BEEXPECTEDINTHISSOCIOECONOMICGROUP4HEREFORE ALL INTERVIEWSWERECONDUCTEDIN%NGLISH 0UBLICRELATIONSACTIVITIES

3EVERALPUBLICRELATIONSACTIVITIESWEREUNDERTAKENTO ENHANCE COMMUNITY ACCEPTANCE AND HELP ENSURE THE SUCCESSFULIMPLEMENTATIONOFTHESTUDY4HEPROJECTWAS LAUNCHEDOFFICIALLYBYTHE$EPUTY-INISTEROF(EALTH THE6ICE #HANCELLOROFTHE5NIVERSITYOF'HANA AND REPRESENTATIVES OF 7(/ AND 5.)#%& IN 'HANA (EALTH RELATED ORGANIZATIONS PHYSICIANS AND NURSES FROM ALL PARTICIPATING HOSPITALS AND THE MEDIA WERE PRESENT4HE$EPUTY-INISTEROF(EALTHAWARDEDABABY DIPLOMATOTHEFIRSTMOTHERRECRUITEDTOTHESTUDY4HE LOCALPRINCIPALINVESTIGATORSALSOAPPEAREDONPOPULAR TELEVISION AND RADIO PROGRAMS TO PRESENT THE -'23 PROJECTTOTHEPUBLIC "REASTFEEDINGINFORMATIONANDOTHERLEAFLETSDESCRIB ING FATHERS ROLES IN SUPPORTING THEIR BREASTFEEDING WIVES WERE PROVIDED TO SUBJECTS AND THEIR FAMILIES %ACH INFANT WAS PRESENTED WITH A BABY PARTICIPATION DIPLOMAANDABIBWITHTHEPROJECTSLOGO!TONEYEAROF AGE ALLSTUDYINFANTSWEREGIVENPERSONALIZEDBIRTHDAY CARDSANDANEDUCATIONALTOY!TTWOYEARS EACHCHILD 4!",%%LIGIBILITYCRITERIAFORENROLLMENTOFCHILDRENATTHE 'HANAIANSITE !BSENCEOFSIGNIFICANTPERINATALMORBIDITYNEWBORNSWITH POSTNATALSTAYININTENSIVECAREHOURSEXCLUDED 3OCIOECONOMICCRITERIA &ATHERHASPOLYTECHNICEDUCATIONANDINCOME MILLIONCEDIS &ATHERHASUNIVERSITYEDUCATIONANDINCOME  CEDIS 53 CEDISEXCHANGERATE*ULY 

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RECEIVEDABOOK &ORTHECROSS SECTIONALSTUDY DAY CARECENTERHEADS ORDIRECTORSWEREINVITEDTOATTENDAONE DAYWORKSHOP )TSPURPOSEWASTOEXPLAINTHEGOALSANDOBJECTIVESOF THE -'23 CROSS SECTIONAL COMPONENT AND THE ROLES THEYANDTHEIRCENTERSCOULDPLAY4HEKEYNOTESPEAKER ATTHEWORKSHOPWASTHE$EPUTY-INISTEROF%DUCATION (EENCOURAGEDALLTHECENTERSTOSUPPORTTHEPROJECT

)MPLEMENTATIONOFTHELONGITUDINALSTUDY 3AMPLINGSTRATEGY

4HE AVERAGE NUMBER OF MONTHLY DELIVERIES IN THE  PARTICIPATING HOSPITALS AND OTHER DELIVERY SITES WAS ABOUT !SUCCESSFULRECRUITMENTRATEFROMTHAT POOL OF LESS THAN  WAS ANTICIPATED BASED ON THE EXPECTEDPREVALENCEOFEXCLUSIONCRITERIAANDREFUSALS AMONGWOMENDELIVERINGATTHEVARIOUSSITES!RECRUIT MENTRATEOFORCHILDRENPERWEEKWASNECESSARY TO MEET THE PROJECTS TARGET OF RECRUITING  ELIGIBLE INFANTS IN ONE YEAR 4HUS ALL INFANTS BORN IN THE  STUDYHOSPITALSANDOTHERDELIVERYFACILITIESWHOSEPAR ENTSRESIDEDINTHESTUDYAREASWERESCREENED

ONE MEMBER OF EACH PAIR THE OTHER MEMBER OF THE PAIRWASROTATEDAMONGOTHERFOLLOW UPTEAMSEVERY TWOMONTHS AFTEREACHBIMONTHLYEVERYTWOMONTHS ANTHROPOMETRICSTANDARDIZATIONSESSION;= !T THE FIRST FOLLOW UP HOME VISIT THE STUDY WAS REVIEWEDWITHMOTHERSANDTHEIRHUSBANDS IFPRESENT ANDWRITTENCONSENTTOPARTICIPATEWASOBTAINEDATTHIS TIME4HISVISITALSOPROVIDEDASECONDOPPORTUNITYTO CONFIRMTHEMOTHERSANDINFANTSELIGIBILITY-OTHERS WHOWEREENROLLEDATTHEHOSPITALVISITBUTWEREFOUND NOTTOHAVECOMPLIEDWITHSTUDYFEEDINGRECOMMENDA TIONSORNOTTOHAVECONFORMEDWITHOTHERINCLUSION REQUIREMENTS WERE CLASSIFIED AShHIDDEN INELIGIBLESv 4HOSEWHOREMAINEDELIGIBLEBUTRESCINDEDTHEIRDECI SIONTOPARTICIPATEWERECLASSIFIEDAShHIDDENREFUSALSv (IDDENINELIGIBLESANDHIDDENREFUSALSWEREEXCLUDED FROMTHESTUDYANDREPLACEDINTHESAMPLEFOLLOWING THE-'23PROTOCOL;=%LIGIBLEMOTHERSWHODROPPED OUT OF THE STUDY AFTER THE FIRST FOLLOW UP VISIT WERE REQUESTED TO CONSENT TO ONE MEASUREMENT WHEN THE CHILDREACHEDMONTHS 4HE MOTOR DEVELOPMENT STUDY AND THE  MONTH FOLLOW UPVISITOFREFUSALSANDDROPOUTSWERECONDUCTED INACCORDANCEWITHTHE-'23PROTOCOL; = ,ACTATIONSUPPORTANDCOMPLEMENTARYFEEDING

3CREENINGANDENROLLMENTOFCHILDREN

(OSPITALCONTACTNURSESASSISTEDINIDENTIFYINGPOTEN TIALLY ELIGIBLE MOTHERS 5SING A SIMPLE ONE PAGE PRE SCREENING FORM THE CONTACT NURSE ASKED PROSPECTIVE SUBJECTS IF THEY LIVED IN ANY OF THE STUDY AREAS AND INQUIREDABOUTTHEHUSBANDSYEARSOFFORMALEDUCATION )FBOTHCRITERIAWEREMET THEMOTHERSANDTHEIRINFANTS WERECONSIDEREDPOTENTIALLYELIGIBLE)NCASESWHERETHE MOTHERSWEREUNCERTAINABOUTTHEIRHUSBANDSEDUCA TIONAL LEVEL RESIDENCE IN ONE OF THE DESIGNATED AREAS WASSUFFICIENTTOESTABLISHPOTENTIALELIGIBILITY#ONTACT NURSESWEREASKEDTOREPORTPOTENTIALLYELIGIBLEMOTHERS TOTHESITESCOORDINATIONOFFICE5NFORTUNATELY NOTALL CONTACTNURSESWEREEQUALLYCOOPERATIVE4OCOMPEN SATEFORTHIS THESCREENINGTEAMSVISITEDALLHOSPITALS ANDOTHERDELIVERYFACILITIESATINTERVALSOFLESSTHAN HOURS4HEHOSPITALWITHTHEHIGHESTNUMBEROFDAILY BIRTHSWASVISITEDTWICEDAILY INTHEMORNINGANDLATE AFTERNOON 3UBJECTSFORWHOMNOPRELIMINARYEXCLUSIONCRITE RIONWASIDENTIFIEDWEREINTERVIEWEDBYTHESCREENING TEAM AND NEWBORN ANTHROPOMETRIC MEASUREMENTS WERE OBTAINED %LIGIBLE MOTHERS WHO WERE WILLING TO PARTICIPATE IN THE STUDY GAVE ORAL CONSENT AT THE HOSPITAL

4HEENROLLEDMOTHERSUSUALLYRECEIVEDTHEFIRSTLACTA TIONSUPPORTVISITINTHEHOSPITAL)NCASESWHERETHIS WASNOTPOSSIBLE THEYWEREVISITEDNOMORETHANTHREE DAYS AFTER DISCHARGE!FTER THIS INITIAL VISIT THE LACTA TIONSUPPORTTEAMMADEHOMEVISITSATONEANDTWO WEEKSANDATTHREEANDSIXMONTHS ASSPECIFIEDINTHE -'23PROTOCOL(OWEVER EXTRAVISITSWERESCHEDULED ATONEANDTWOMONTHSFORPRIMIPAROUSMOTHERSAND FORMOTHERSWHOHADBREASTFEEDINGPROBLEMSATWEEKS ONEANDTWO"ETWEENTHREEANDSIXMONTHS NOEXTRA VISITS WERE SCHEDULED EXCEPT WHEN REQUESTED BY THE MOTHER 4HE MOTHERS WERE ADVISED TO INTRODUCE COMPLE MENTARYFOODSTOTHEINFANTBYSIXMONTHSOFAGE4HE COMPLEMENTARYFEEDINGGUIDELINES SHOWNINTABLE WERE DEVELOPED BY THE .UTRITION 5NIT OF THE 'HANA (EALTH 3ERVICE ;= 4HESE GUIDELINES WERE DEVELOPED TO FACILITATE THE ACTIVITIES OF FIELD EXTENSION WORKERS INVOLVEDINNUTRITIONEDUCATION

)MPLEMENTATIONOFTHECROSS SECTIONAL STUDY 3AMPLINGSTRATEGY

! SUMMARY OF THE PROTOCOL OF THE CROSS SECTIONAL COMPONENT IS GIVEN ELSEWHERE IN THIS SUPPLEMENT %ACHENROLLEDSUBJECTWASASSIGNEDAPAIROFFOLLOW UP ;=4HECROSS SECTIONALCOMPONENTSOUGHTTORECRUIT INTERVIEWERS%ACHSUBJECTWASVISITEDCONSISTENTLYBY ANDMEASURECHILDRENBETWEENTHEAGESOFAND &OLLOW UPLOGISTICS

3 4!",%#OMPLEMENTARYFEEDINGGUIDELINESATTHE'HANA IANSITE "EFOREMONTHS GIVEONLYBREASTMILK$ONOTGIVEANY WATER FRUITSFRUITJUICEORPORRIDGE )NTRODUCENEWFOODSGRADUALLYBYMONTHSOFAGE 4HEFIRSTCOMPLEMENTARYFOODMAYBECEREALPORRIDGE GIVENBYSPOONONEORTWOTIMESADAY !STHECHILDGROWS INCREASETHEAMOUNTAND FREQUENCYOFFEEDING #ONTINUETOBREASTFEEDONDEMAND &EEDAVARIETYOFFOODS #EREALPORRIDGE %NRICHCEREALPORRIDGE SOUPS ANDSTEWSWITHATLEAST ONEOFTHEFOLLOWINGMILK MASHEDBEANS FISH POWDER MASHEDPOULTRYORMEAT GROUNDNUTPASTE VEGETABLEOIL &RUITSANDVEGETABLES &EEDIRON RICHFOODSSUCHASFISH FISHPOWDER MEAT ANDPOULTRY 'IVEFRUITORFRUITJUICEWITHMEALSORSNACKSTOHELP ABSORBIRONINOTHERFOODS &EEDVITAMIN!nRICHFOODSSUCHASPALMOIL MANGOES PAWPAW CARROTS GREENLEAFYVEGETABLES ANDEGGS 4HECHILDSFOODMUSTBEWELLCOOKED MASHED ANDSOFTENED $ONOTADDPEPPEROROTHERSPICESTOTHECHILDSFOOD 7ASHHANDSWITHCLEANWATERANDSOAPBEFORETOUCHING FOODORFEEDINGTHECHILD 4HECHILDSHOULDHAVEHISORHEROWNBOWLSOTHATTHEREIS NOCOMPETITIONWITHOLDERCHILDRENFORFOOD #HILDRENWHOREFUSEFOODSHOULDBEPERSUADEDTOEATDO NOTFORCETHECHILDTOEAT$ONOTFUSSOVERACHILDWHO REFUSESTOEAT-AKEMEALTIMESHAPPYTIMES

MONTHSWHOWERESIMILARTOTHOSEENROLLEDINTHELON GITUDINAL COMPONENT6ARIOUS RECRUITMENT STRATEGIES TOACCOMPLISHTHISAIMWERECONSIDERED)N!CCRA THE MOSTSUITABLESTRATEGYWASRECRUITMENTFROMDAY CARE CENTERS BECAUSE MOST MOTHERS ENROLLED IN THE STUDY WORKEDOUTSIDETHEHOME ANDITWASCOMMONPRACTICE AMONGTHETARGETEDSOCIOECONOMICGROUPTOSENDTHEIR PRESCHOOLCHILDRENTOCRÞCHESANDNURSERIES 4HE PARENTS IN THE LONGITUDINAL STUDY WERE INTER VIEWEDINORDERTODETERMINEWHICHDAY CARECENTERS THETARGETPOPULATIONCHOSEFORTHEIRCHILDRENANDAT WHATAGETHECHILDRENBEGANTOATTENDTHEM!TOTALOF  DAY CARE CENTERS WERE IDENTIFIED %IGHTY OF THESE EITHERWEREUSEDORWEREINTENDEDTOBEUSEDBY OFTHEMOTHERSINTHELONGITUDINALSTUDY4HEDAY CARECENTERSSERVEDABOUT CHILDRENBETWEENTHE AGES OF  AND  MONTHS WHO RESIDED IN THE STUDY AREAS 4HE FOLLOWING RATES WERE APPLIED TO ESTIMATE THENUMBERTOBESCREENEDLOWSOCIOECONOMICSTATUS  TWIN BIRTHS  GESTATIONAL AGE   WEEKS OR *WEEKS SIGNIFICANTMORBIDITY BREASTFED   MONTHS  ENROLLED IN THE LONGITUDINAL STUDY REFUSALS ANDRESIDENCEOUTOFSTUDYAREA  /NTHISBASIS ITWASESTIMATEDTHATOFTHESAMPLE WASPOTENTIALLYELIGIBLE&OLLOWINGTHE-'23PROTOCOL

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3TANDARDIZATION QUALITYCONTROL ANDDATA MANAGEMENTACTIVITIES 3EVERAL MEASURES WERE PUT IN PLACE TO ENSURE DATA QUALITY 4HESE HAVE BEEN DESCRIBED ELSEWHERE IN THIS SUPPLEMENT ;= 3TANDARDIZED PROCEDURES TO ENSURE ACCURATE AND PRECISE ANTHROPOMETRIC MEASUREMENTS WEREFOLLOWED ASDESCRIBEDINTHE-'23PROTOCOL;= 'ENERALLY NEWBORNSWERERECRUITEDFORTHESCREENING TEAMSBIMONTHLYEVERYTWOMONTHS STANDARDIZATION SESSION 4HE FOLLOW UP TEAM CONDUCTED THEIR STAND ARDIZATIONSESSIONSWITHINFANTSAGEDTOMONTHS RECRUITEDATGROWTHMONITORINGCLINICS&ORTHEHEIGHT STANDARDIZATIONSESSIONS OLDERCHILDRENWERERECRUITED FROMNURSERYSCHOOL/NEOFTHETWO7(/ DESIGNATED LEADANTHROPOMETRISTSPARTICIPATEDONCEANNUALLYINA STANDARDIZATIONSESSIONTOASSESSTHEACCURACYANDPRE CISIONOFEACHINTERVIEWERSMEASUREMENTS;= "IMONTHLY MOTOR DEVELOPMENT STANDARDIZATION EXERCISESWEREALSOHELDFORALLTHEINTERVIEWERSASSIGNED THIS FUNCTION 3TAFF FROM THE 7(/ #OORDINATING #ENTREVISITEDTHESITEEVERYYEARTOASSESSTHETEAMS PERFORMANCEANDPROVIDETRAININGASNEEDED;= 4EAM SUPERVISORS CHECKED FORMS ROUTINELY FOR CONSISTENCYANDCOMPLETENESSOFRECORDEDRESPONSES 4HE FORMS APPROVED BY THE TEAM SUPERVISORS WERE FORWARDEDTOTHESTAFFINCHARGEOFQUALITYCONTROLFOR AFINALCHECKBEFOREDATAENTRY VERIFICATION ANDVALIDA

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