Introduction Malnutrition is a significant cause of morbidity and mortality for children living in low- and middle-income countries (LMICs). For older children (5-12 years old) with sickle cell anemia (SCA), malnutrition (weight for age Z-score <-1.0) is associated with premature death (Klein et al., Blood Advances, 2023). Despite the high prevalence of malnutrition in children with SCA living in LMICs, no studies have assessed nutrition education and vocational training for caregivers of children with SCA and malnutrition.

In non-SCA populations, vocational training has been shown to improve income and employment, while nutrition education enhances caregiver knowledge and feeding practices. We tested the feasibility of a novel program providing both nutrition education and vocational training to caregivers of older children with SCA and severe malnutrition.

Methods We conducted an ancillary feasibility cohort study nested within our trial for the management of severe acute malnutrition in children aged 5-12 years old with SCA (SAMS trial, NCT03634488) in Kano, Nigeria. Caregivers of children enrolled in the SAMS trial were invited to participate in nutrition education and vocational training. The primary outcomes for this feasibility study were recruitment, attendance, and retention to the nutrition education and vocational training sessions for caregivers of children participating in the SAMS trial.

Caregivers attended three full-day nutrition education sessions. Each caregiver was accompanied by a designated partner of their choosing who played an influential role in the child's dietary intake. Sessions, led by a dietician, included: (1) introduction to nutrition needs in children with SCA, preparation and preservation of local nutrient-rich foods, and feeding practices; (2) demonstration of a high-protein, high-calorie formula consisting of millet, soybeans, and peanuts; and (3) caregiver-led practical preparation. Caregivers also attended three separate vocational sessions led by a local trainer and two assistants. During these sessions, caregivers learned income-generating skills of their choice and received training on household budgeting. Pre-intervention questionnaires assessed caregivers' baseline nutrition knowledge, feeding practices, household income, and food purchasing habits. Post-intervention questionnaires, completed at the final visit and four-week follow-up, evaluated the implementation of nutrition education and perceptions and impact of vocational training.

Results The enrollment and retention rates were both 100% (n = 27). Attendance was 100% among caregivers (n = 27) and 98.8% among designated partners (n = 27), with one designated partner missing the third nutrition visit. Most caregivers were mothers, participating in 79 of 81 nutrition visits and 80 of 81 vocational training sessions. In three sessions, a foster parent or a relative substituted for the mother. At baseline, 54% of caregivers (13 of 24) were not employed. The most frequently selected designated partner was the child's sister (n = 12 of 27, 44%), followed by the child's aunt/uncle (n = 7 of 27, 25%). Following the intervention, 100% of caregivers (n = 27 of 27) reported incorporating new foods into their child's diet, and 82% (n = 22 of 27) reported implementing the nutrition education daily over the past seven days. Among those with available data, 95% (n = 20 of 21) indicated that vocational training positively influenced their household income. Of these, 80% (n = 16 of 20) reported using income from vocational activities to purchase food, and 45% (n = 9 of 20) reported generating additional income because of implementing skills learned during vocational training.

Conclusion Incorporating a combined nutrition education and vocational training program for caregivers of children with SCA is feasible based on the high recruitment, attendance, and retention rates. Caregivers showed meaningful improvements in knowledge, nutrition-related behaviors, and financial capacity, which can translate into better dietary care for children with SCA. This training was completed locally and could be repeated with local funding or even by an SCA community-based organization, and may serve as a model for future research on malnutrition in understudied populations. Larger studies with longer follow-up are warranted to assess its impact on health outcomes.

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2025
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